Segmented intramedullary system and methods

ABSTRACT

Methods of manufacturing, assembling, or treating a patient with an implantable segmented intramedullary structure adapted to be received in the intramedullary canal of a bone configurable between a relatively flexible, bent configuration for implantation or extraction and a relatively rigid, straightened configuration for bone treatment. The segmented intramedullary structure comprises a plurality of interconnected segments with a first interface and a complementarily-shaped second interface such that the first interface of a segment cooperatively engages the second interface of an adjacent segment. The segments define a channel for a tensioning member to lock the structure in a compressed configuration.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. application Ser. No.12/052,919, filed Mar. 21, 2008, which claims the benefit of priorityfrom U.S. Provisional No. 60/896,342 filed Mar. 22, 2007, all of whichare incorporated by reference in their entireties herein.

This application claims the benefit of priority from U.S. ProvisionalNo. 61/055,747, filed May 23, 2008, which is incorporated by referencein its entirety herein.

BACKGROUND

Embodiments of the present invention relate to an orthopedic prosthesis,and, more particularly, to an implantable structure, commonly called anintramedullary or IM nail, that is adapted to be received in theintramedullary canal for the treatment of long bone fractures.

SUMMARY

The intramedullary structure of the present disclosure, in oneembodiment, utilizes a plurality of segments that are preferablyintroduced into the intramedullary canal over a guide member that hasbeen previously introduced into the intramedullary canal through apercutaneous access hole, or access port at an access site. Each segmentis preferably configured so that it interconnects with the segmentsadjacent thereto. In one embodiment an elongated tensioning member isreceived interiorly of the segments and is secured to the end segmentsto secure all the segments in the structure together. In one embodiment,the guide member is a wire or cable that can also serve as thetensioning member. In one embodiment each segment may have an aperture,in the form of an open interior, so that the segment can be threadedover a guide or tensioning member. The segments also have opposed endsthat preferably are complementarily-shaped so that a first interface ofa first segment is adapted to cooperatively engage with a secondinterface of a second segment adjacent thereto. In one embodiment eachsegment has a male end portion and a complementarily-shaped female endportion.

In one embodiment a method for tensioning a surgical elongate memberincludes providing an implant, actuating a tensioner and locking alocking mechanism on the elongate member to maintain a selected tension.The implant has an elongate member connected thereto, and a lockingfeature on the implant. The locking feature circumferentially engagesthe elongate member to lock onto the elongate member. The step ofactuating a tensioner regulates the tension on the elongate member. Inone embodiment the implant is a segmented intramedullary fracturefixation device. In one embodiment the locking mechanism comprises acollet. In one embodiment the method also includes actuating the lockingmechanism actuator to lock the locking mechanism onto the elongatemember after regulating the tension on the elongate member.

In one embodiment a method for tensioning a surgical elongate memberincludes connecting a first location on an elongate member to animplant, locking a locking feature onto a second location on theelongate member, actuating a tensioner to regulate the tension on theelongate member between the first location and the second location, andlocking a locking mechanism onto a third location on the elongatemember. The locking feature circumferentially engages the elongatemember to lock onto the elongate member. In one embodiment the implantis a segmented intramedullary fracture fixation device. In oneembodiment the third location is between the first location and thesecond location. In one embodiment the locking mechanism actuator locksthe locking mechanism onto the third location on the elongate memberafter regulating the tension on the elongate member.

In one embodiment a method of treating a fracture in a bone includesproviding an elongate fixation device, advancing the fixation devicealong a nonlinear path while the fixation device is in a flexible state,until the fixation device spans a fracture in the bone, engaging thebone with the distal end of the fixation device, transforming thefixation device from the flexible state to a substantially rigid state,axially shortening the fixation device to apply compression across thefracture, and locking the fixation device in the substantially rigidstate. The elongate fixation device has a proximal end and a distal end.In one embodiment the axially shortening step and the locking step areaccomplished simultaneously. In one embodiment the axially shorteningstep is accomplished following the engaging step. In one embodiment thetransforming step comprises proximally retracting a tensioning elementwith respect to the proximal end. In one embodiment the locking stepcomprises locking the tension element in a compression lock. In oneembodiment the axially shortening the fixation device is decreases afixation device length by up to about 5 mm.

In one embodiment a method of locking an implant in a rigidconfiguration, includes tensioning an elongate member disposed throughtwo or more segments of an implant, locking the elongate member at alock, and cutting the elongate member proximal to the lock.

Other features and aspects will become apparent upon reference to theaccompanying drawings and description.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other features, embodiments, and advantages of the presentinvention will now be described in connection with preferred embodimentsof the invention, in reference to the accompanying drawings. Theillustrated embodiments, however, are merely examples and are notintended to limit the invention.

FIG. 1 is a perspective of an assembled segmented intramedullarystructure, such as a nail, according to a first embodiment of thedisclosure.

FIG. 2 is a perspective view of a single segment of the intramedullarynail of FIG. 1.

FIG. 3 is a longitudinal cross-sectional view of the segment of FIG. 2.

FIG. 4 is a perspective view of an intramedullary nail utilizing asecond embodiment of an individual nail segment.

FIGS. 5 and 6 are perspective views of a third embodiment of anindividual segment for use in an intramedullary structure and aplurality of such segments received over a guide member.

FIGS. 7 and 8 are perspective views of a fourth embodiment of anindividual segment and a plurality of such structures received over aguide member.

FIGS. 9 and 10 are perspective views of a fifth embodiment of anindividual segment and a plurality of such segments mounted together.

FIGS. 11 and 12 are perspective views of a sixth embodiment of a segmentfor use in an intramedullary nail in which a plurality of peripheralrods is used in the assembled nail.

FIG. 13 is a perspective of a seventh embodiment of an IM nail in whichthe segments are connected to each other by a hinge member so that thenail can be inserted into the intramedullary canal through an accesshole that is oblique to the axis of the intramedullary canal.

FIGS. 14-22 schematically illustrate the procedure for installing asegmented intramedullary nail according to one embodiment of the presentinvention into the intramedullary canal of a long bone.

FIG. 23 is a perspective view of a system for implanting anintramedullary fracture fixation device comprising the implantablefracture fixation device, a screw guide, and a cable tensioner accordingto one embodiment of the present invention.

FIG. 24 is a front view of the implantable intramedullary fracturefixation device shown in FIG. 23.

FIG. 25 is a front view of the proximal-most segment of the implantablefracture fixation device shown in FIG. 24.

FIG. 26 is a front view of a typical intermediate segment of theimplantable fracture fixation device shown in FIG. 24.

FIG. 27 is a front view of the distal-most segment of the implantablefracture fixation device shown in FIG. 24.

FIGS. 28 and 29 are perspective views of the intermediate segment shownin FIG. 26.

FIGS. 30 and 31 are perspective view of the proximal-most segment shownin FIG. 25.

FIG. 32 is a cross-sectional view of the distal portion of theimplantable fracture fixation device of FIG. 23, showing details as tothe distal-most segment.

FIG. 33 is a perspective view of an expander forming a portion of thedistal-most segment of FIG. 32.

FIG. 34 is a perspective view of a screw guide interface adapted to beseated on the proximal end of the implantable fracture fixation deviceshown in FIG. 23.

FIG. 35 is a cross-sectional view of the screw guide interface and theproximal end of the fracture fixation structure shown in FIG. 24.

FIG. 36 is an enlarged perspective view of the cable tensioner accordingto one embodiment of the present invention.

FIG. 37 is a cross-sectional view of the cable tensioner shown in FIG.36.

FIG. 38 is an enlarged cross-sectional view of the cooperating structureof the cable tensioner and the proximal-end segment of the fracturefixation device according to one embodiment of the present invention.

FIGS. 39A-39B are schematic representations of secondary compression ina long bone using an embodiment of a segmented intramedullary structure.

FIGS. 40A-40B are schematic representations of secondary compression ina humerus using an embodiment of a segmented intramedullary structure.

FIG. 41A is a schematic side view of an embodiment of a stepped segmentof a segmented intramedullary structure.

FIG. 41B is a schematic cross-sectional side view of the stepped segmentof FIG. 41A.

FIG. 41C is a schematic perspective view of the stepped segment of FIG.41A.

FIG. 42A is a schematic side view of an embodiment of a pair of adjacentstepped segments of FIG. 41A in a bent configuration.

FIG. 42B is a schematic cross-sectional side view of the pair ofadjacent stepped segments of FIG. 41A in a bent configuration.

FIG. 42C is a schematic perspective view of the pair of adjacent steppedsegments of FIG. 41A in a bent configuration.

FIG. 43A is a schematic side view of an embodiment of a pair of adjacentstepped segments of FIG. 41A in a straightened, or compressedconfiguration.

FIG. 43B is a schematic cross-sectional side view of the pair ofadjacent stepped segments of FIG. 41A in a straightened configuration.

FIG. 43C is a schematic perspective view of the pair of adjacent steppedsegments of FIG. 41A in a straightened configuration.

FIG. 44A is a schematic front view of an embodiment of a snap segment ofa segmented intramedullary structure.

FIG. 44B is a schematic cross-sectional front view of the snap segmentof FIG. 44A.

FIG. 44C is a schematic side view of an embodiment the snap segment ofFIG. 44A.

FIG. 44D is a schematic cross-sectional side view of the snap segment ofFIG. 44A.

FIG. 44E is a schematic perspective view of the snap segment of FIG.44A.

FIG. 45A is a schematic side view of an embodiment of a pair of adjacentsnap segments of FIG. 44A in a bent configuration.

FIG. 45B is a schematic cross-sectional side view of the pair ofadjacent snap segments of FIG. 44A in a bent configuration.

FIG. 45C is a schematic front view of the pair of adjacent snap segmentsof FIG. 44A in a bent configuration.

FIG. 45D is a schematic cross-sectional front view of the pair ofadjacent snap segments of FIG. 44A in a bent configuration.

FIG. 45E is a schematic perspective view of the pair of adjacent snapsegments of FIG. 44A in a bent configuration.

FIG. 46A is a schematic side view of an embodiment of a pair of adjacentsnap segments of FIG. 44A in a straightened configuration.

FIG. 46B is a schematic cross-sectional view of the pair of adjacentsnap segments of FIG. 44A in a straightened configuration.

FIG. 46C is a schematic front view of the pair of adjacent snap segmentsof FIG. 44A in a straightened configuration.

FIG. 46D is a schematic cross-sectional front view of the pair ofadjacent snap segments of FIG. 44A in a straightened configuration.

FIG. 46E is a schematic perspective view of the pair of adjacent snapsegments of FIG. 44A in a straightened configuration.

FIG. 47A is a schematic side view of an embodiment of a unidirectionalsegment of a segmented intramedullary structure.

FIG. 47B is a schematic cross-sectional side view of the unidirectionalsegment of FIG. 47A.

FIG. 47C is a schematic perspective view of the unidirectional segmentof FIG. 47A.

FIG. 48A is a schematic side view of another embodiment of aunidirectional segment of a segmented intramedullary structure.

FIG. 48B is a schematic cross-sectional side view of the unidirectionalsegment of FIG. 48A.

FIG. 48C is a schematic perspective view of the unidirectional segmentof FIG. 48A.

FIG. 49A is a schematic side view of an embodiment of a pair of adjacentunidirectional segments of FIG. 48A in a bent configuration.

FIG. 49B is a schematic transparent cross-sectional side view of thepair of adjacent unidirectional segments of FIG. 48A in a bentconfiguration.

FIG. 49C is a schematic partial cross-sectional side view of the pair ofadjacent unidirectional segments of FIG. 48A in a bent configuration.

FIG. 50A is a schematic side view of an embodiment of a pair of adjacentunidirectional segments of FIG. 48A in a straightened configuration.

FIG. 50B is a schematic transparent cross-sectional side view of thepair of adjacent unidirectional segments of FIG. 48A in a straightenedconfiguration.

FIG. 50C is a schematic partial perspective side view of the pair ofadjacent unidirectional segments of FIG. 48A in a straightenedconfiguration.

FIG. 51A is a schematic side view of an embodiment of a threaded segmentof a segmented intramedullary structure.

FIG. 51B is a schematic cross-sectional side view of the threadedsegment of FIG. 51A.

FIG. 51C is a schematic perspective view of the threaded segment of FIG.51A.

FIG. 52A is a schematic side view of another embodiment of a threadedsegment of a segmented intramedullary structure.

FIG. 52B is a schematic cross-sectional side view of the threadedsegment of FIG. 52A.

FIG. 52C is a schematic perspective view of the threaded segment of FIG.52A.

FIG. 53A is a schematic side view of an embodiment of a pair of adjacentthreaded segments of FIG. 52A in a bent configuration.

FIG. 53B is a schematic transparent cross-sectional side view of thepair of adjacent threaded segments of FIG. 52A in a bent configuration.

FIG. 53C is a schematic partial cross-sectional side view of the pair ofadjacent threaded segments of FIG. 52A in a bent configuration.

FIG. 54A is a schematic side view of an embodiment of a pair of adjacentthreaded segments of FIG. 52A in a straightened configuration.

FIG. 54B is a schematic transparent cross-sectional side view of thepair of adjacent threaded segments of FIG. 52A in a straightenedconfiguration.

FIG. 54C is a schematic partial perspective side view of the pair ofadjacent threaded segments of FIG. 52A in a straightened configuration.

FIG. 55A is a schematic side view of an embodiment of a snap ringsegment of a segmented intramedullary structure.

FIG. 55B is a schematic cross-sectional side view of the snap ringsegment of FIG. 55A.

FIG. 55C is a schematic front view of the snap ring segment of FIG. 55A.

FIG. 55D is a schematic cross-sectional front view of the snap ringsegment of FIG. 55A.

FIG. 55E is a schematic perspective view of the snap ring segment ofFIG. 55A.

FIG. 56A is a schematic side view of an embodiment of a pair of adjacentsnap ring segments of FIG. 55A in a bent configuration.

FIG. 56B is a schematic cross-sectional side view of the pair ofadjacent snap ring segments of FIG. 55A in a bent configuration.

FIG. 56C is a schematic front view of the pair of adjacent snap ringsegments of FIG. 55A in a bent configuration.

FIG. 56D is a schematic cross-sectional front view of the pair ofadjacent snap ring segments of FIG. 55A in a bent configuration.

FIG. 56E is a schematic perspective view of the pair of adjacent snapring segments of FIG. 55A in a bent configuration.

FIG. 57A is a schematic side view of an embodiment of a pair of adjacentsnap ring segments of FIG. 55A in a straightened, compressedconfiguration.

FIG. 57B is a schematic cross-sectional view of the pair of adjacentsnap ring segments of FIG. 55A in a straightened configuration.

FIG. 57C is a schematic front view of the pair of adjacent snap ringsegments of FIG. 55A in a straightened configuration.

FIG. 57D is a schematic cross-sectional front view of the pair ofadjacent snap ring segments of FIG. 55A in a straightened configuration.

FIG. 57E is a schematic perspective view of the pair of adjacent snapring segments of FIG. 55A in a straightened configuration.

FIG. 58A is a schematic side view of an embodiment of a pair of adjacentsegments in a detached configuration in one embodiment of a segmentedintramedullary structure.

FIG. 58B is a schematic side view of the pair of adjacent segments ofFIG. 58A in a distracted configuration with an axial displacement lengthbetween the adjacent segments.

FIG. 58C is a schematic side view of the pair of adjacent segments ofFIG. 58A in a bent configuration with a rotational displacement anglebetween the adjacent segments.

FIG. 58D is a schematic side view of the pair of adjacent segments ofFIG. 58A in a compressed configuration.

FIG. 59A is a schematic perspective view of an embodiment of a segmentedintramedullary structure in a compressed configuration.

FIG. 59B is a schematic side view of the segmented intramedullarystructure of FIG. 59A.

FIG. 59C is a schematic front view of the segmented intramedullarystructure of FIG. 59A.

FIG. 59D is a schematic top view of the segmented intramedullarystructure of FIG. 59A.

FIG. 59E is a schematic rear view of the segmented intramedullarystructure of FIG. 59A.

FIG. 59F is a schematic bottom view of the segmented intramedullarystructure of FIG. 59A.

FIG. 59G is a schematic perspective partially exploded view of thesegmented intramedullary structure of FIG. 59A.

FIG. 59H is a schematic cross-sectional side view of the segmentedintramedullary structure of FIG. 59A.

FIG. 60 is a schematic side view of various embodiments of segmentedintramedullary structures in bent configurations.

FIG. 61 is a schematic perspective view of an embodiment of across-screw distal fixation structure segment of an intramedullarystructure.

FIG. 62 is a schematic perspective view of an embodiment of a polymerdistal fixation segment of an intramedullary structure.

FIG. 63 is a schematic perspective view of an embodiment of aradially-expandable distal fixation segment of an intramedullarystructure.

FIG. 64 is a schematic cross sectional side view of the cross-screwdistal fixation structure segment of an intramedullary structure of FIG.61.

FIG. 65 is a schematic side view of a cable and cable tube according toone embodiment of the present invention.

FIG. 65A is a schematic cross sectional view of the cable and the cabletube according to FIG. 65.

FIG. 66 is a schematic perspective view of an embodiment of a proximalend segment.

FIG. 67 is a schematic top view of the proximal end segment of FIG. 66.

FIG. 68 is a schematic cross sectional side view of the proximal endsegment of FIG. 66.

FIG. 69 is a schematic perspective view of a cable collet anchoraccording to one embodiment of the present invention.

FIG. 70 is a schematic side view of a surgical procedure in a boneaccording to an embodiment of the present invention.

FIG. 71 is a schematic side view of a surgical procedure in a bone witha broach according to an embodiment of the present invention.

FIG. 72 is a schematic side view of a surgical procedure in a bone witha guide wire according to an embodiment of the present invention.

FIG. 73 is a schematic side view of a surgical procedure in a bone witha measurement of implant length according to an embodiment of thepresent invention.

FIG. 74 is a schematic side view of a surgical procedure in a bone witha bone reamer according to an embodiment of the present invention.

FIG. 75 is a schematic side view of a surgical procedure in a bone withan exchange tube according to an embodiment of the present invention.

FIG. 76 is a schematic side view of a segmented intramedullary structurebeing inserted in a bent configuration in to a sectional view of a boneaccording to an embodiment of the present invention.

FIG. 77 is a schematic side view of a surgical procedure in a bone witha segmented intramedullary structure being inserted in a bentconfiguration in to a sectional view of a bone with a proximal drillguide according to an embodiment of the present invention.

FIG. 78 is a schematic side view of a surgical procedure in a bone witha tensioner and a segmented intramedullary structure according to anembodiment of the present invention.

FIG. 79 is a schematic side view of a modular, customizable segmentedintramedullary structure according to an embodiment of the presentinvention.

Throughout the figures, the same reference numerals and characters,unless otherwise stated, are used to denote like features, elements,components or portions of the illustrated embodiments. In certaininstances, similar names may be used to describe similar components withdifferent reference numerals which have certain common or similarfeatures. Moreover, while the subject invention will now be described indetail with reference to the figures, it is done so in connection withthe illustrative embodiments. It is intended that changes andmodifications can be made to the described embodiments without departingfrom the true scope and spirit of the subject invention as defined bythe appended claims.

DETAILED DESCRIPTION

In accordance with the present disclosure, various embodiments of anintramedullary structure are provided that are adapted to be received inthe intramedullary canal of a bone, such as a long bone, including butnot limited to a humerus, tibia, femur, radius, ulna, phalange,metatarsal, metacarpal, clavicle or other long bone. In variousembodiments the structure comprises a plurality of segments, withcomplementary interfaces between the segments. In various embodiment thecomplementary interfaces can comprise complementary surfaces,complimentarily-shaped features, mating male and female portions, nestedfeatures, paired geometries, and the like which can interface aproximal, medial, intermediate, middle, or distal portion, area, or endof the respective segments. In one embodiment a segment has a firstinterface and a complementarily-shaped second end interface, so that thefirst interface of a segment cooperatively engages the second interfaceof an adjacent segment.

In various embodiments the segments can define a channel, aperture orlumen so as to be receivable over an elongate member for introduction ofthe segments into the intramedullary canal. In various embodiments, theelongate member can be a wire, guide wire, pull wire, push wire, cable,rod, threaded rod, or other similar structure. Use of terms related toembodiments of elongate members may be used interchangeably and shouldbe understood to refer to the various types of embodiments of theelongate member being used. For example, cable may be used to describeany number of types of elongate members, but should not be necessarilylimited to use only with a cable. For example, a cable tensioner toolcan be understood to refer to other possible embodiments of elongatemember tensioner tools. In one embodiment the elongate member is atensioning member extending along the length of the segmentedintramedullary structure that cooperates with the two or more segments,such as in one embodiment the end-most segments, of the structure toapply a compressive force along the longitudinal axis of the structure,thus providing the structure with enhanced rigidity. In one embodimentthe compressive force for enhancing rigidity also provides secondarycompression to the surrounding bone segments by brining bone segmentscloser together.

In various embodiments, different combinations of segments can be usedor combined in a modular fashion to assemble custom made structuresbased on the bone and application for the structure. In some embodimentsthe intramedullary structure is removable from the body. In variousembodiments the overall configuration or shape of the intramedullarystructure may be straight, substantially straight, or curved along anyone segment or any sets of segments. Each segment can be substantiallystraight or curved, and any set of straight segments can have interfacesproviding for angles between adjacent segments. In one embodiment theintramedullary structure has a first configuration and a secondconfiguration. In one embodiment the first configuration issubstantially the configuration of the intramedullary structure once itis assembled and delivered into the intramedullary canal. In oneembodiment the second configuration is the configuration of theintramedullary structure once it is locked. In one embodiment anintramedullary structure configuration is linear. In one embodiment anintramedullary structure configuration is substantially linear. In oneembodiment an intramedullary structure configuration is curved. In oneembodiment an intramedullary structure configuration is predetermined.In one embodiment a predetermined configuration mimics the contour ofthe intramedullary canal. In one embodiment an intramedullary structureconfiguration is governed by the native structure of the intramedullarycanal in which the structure is inserted. In one embodiment anintramedullary structure configuration conforms to the structure of thesurrounding tissue. In one embodiment an intramedullary structureconfiguration is flexible. In one embodiment an intramedullary structureconfiguration is substantially rigid. In one embodiment anintramedullary structure configuration is rigid. In one embodiment anintramedullary structure can change from a relatively longerconfiguration to a relatively shorter configuration. In one embodimentan intramedullary structure configuration is movable within one plane.In one embodiment an intramedullary structure configuration is movablein two planes. In one embodiment an intramedullary structureconfiguration is movable in three or more planes. In one embodiment anintramedullary structure configuration is axially compressible. In oneembodiment an intramedullary structure configuration is rotatable abouta longitudinal axis. In one embodiment an intramedullary structureconfiguration is axially rotatable. In one embodiment an intramedullarystructure configuration is locked.

Turning to FIG. 1, a first embodiment of a segmented intramedullarystructure 10 is shown. The illustrated embodiment of the segmentedintramedullary structure 10 comprises eight segments 12 that arereceived over an optional tension rod 14 to provide an intramedullarystructure 10 having an overall length of approximately 175 mm. Ofcourse, the number of segments 12 and the overall length and othergeometric measurements, including but not limited to diameter,curvature, fixation structures, and other features of the segmentedintramedullary structure 10 can vary depending on the size and type ofbone, and can depend upon the length of the intramedullary canal intowhich it is to be inserted, as well as any features the medicalpractitioner elects is preferred for a particular use.

As shown, in one embodiment the ends 16 of the tension rod 14 arethreaded and the segments 12 are maintained thereon by complementarilythreaded members (nuts 18 and washers 20 are shown) received on thethreaded ends 16 of the tension rod 14. However, alternate methods forsecuring the segments 12 to the tension rod 14 may be employed, such asa swage fitting that is received on the tension rod and which seats inthe open interior of the end segments, or a press nut received on thetension rod in engagement with the end segments.

FIGS. 2 and 3 show one embodiment of a single segment 12 of theintramedullary structure shown in FIG. 1. The specific configuration ofthe individual segment 12 shown in FIGS. 2 and 3 is by way of exampleonly. In one embodiment the segment 12 comprises a male end 22 having afrusto-conical outer shape and a female end 24 having a cylindricalouter shape and a frusto-conical inner shape complementarily to theouter shape of the male end 22.

In one embodiment, the overall length of the segment 12 is preferably nogreater than about 32 mm, which allows the segment 12 to be relativelyeasily introduced into the intramedullary canal through a 10 mmpercutaneous access hole that is oriented at approximately 30 degreeswith respect to the bone axis. The largest outside diameter of thesegment 12 is dictated by the inside diameter of the intramedullarycanal. In one embodiment the largest outer diameter of the segment 12 isabout 9 mm. In one embodiment the inside diameter of the male end 22 ofthe segment is approximately 3.6 mm, which allows a 3 mm guide wire orcable to easily pass there through.

In one embodiment components of the implant are made of a biocompatiblematerial of sufficient rigidity and strength, such as Titanium. In oneembodiment the implant comprises materials made of a Titanium Alloy. Inone embodiment the implant comprises material made of Ti-6Al-4V alloy.In one embodiment the segments 12 are made of a biocompatible materialof sufficient rigidity and strength, such as Titanium or its alloys. Inone embodiment the inside surface of the female end 24 and the outsidesurface of the male end 22 may be smooth (“mirror polished”) tofacilitate nesting. In one embodiment the outside surface of the femaleend 24 may be roughened or textured (“knurled”) to promote tissue growththereon. In various embodiments, various coatings may be applied to partor all of the external and/or internal surfaces of the segments. In oneembodiment, segments can be anodized. In one embodiment, anodizingsegment surfaces can reduce the likelihood of cold fusion from bindingparts under compression together.

In the illustrated embodiment, adjacent segments 12 are secured to eachother by a friction fit between the inside surface of the female end andthe outside surface of the male end. However, a more positiveinterlocking can be obtained, if desired, by providing the segments withmechanically-interlocking structures, such as slots and pins, prongs,tabs, screw threads, etc. The segments may also be configured to preventrotational movement there between when assembled. This may beaccomplished by, e.g., providing the outer surface of the male end andthe inner surface of the female end with complementary non-circularcross sections, such as a square with rounded-off corners.Alternatively, or additionally, bone cement or other hardenable surgicalfluid may be introduced into the interior of the segments once in placein the intramedullary canal, to impart additional structural integrityfor the assembly and to help secure the assembled structure in place.

FIG. 4 illustrates an embodiment of an intramedullary structure inaccordance with the present disclosure utilizing a second embodiment ofindividual segments 12A. The male end 22A of the segments 12A comprisean externally-threaded standoff that is received in the complementaryinternally threaded female end 24A of an adjacent segment 12A.

FIGS. 5 and 6 disclose a third embodiment of segments 12B for anintramedullary structure in accordance with the present disclosure. Themale ends 22B of the segments comprise prongs 26 with shoulders ordetents 28 on their distal ends that provide for a snap fit with thecomplementarily-shaped end 24B of the adjacent segment 12B. A series ofinterfitting spaced tabs 30 on the periphery of both the male and femaleends provides for alignment of the segments and serve to preventrotation of the segments 12B with respect to each other. When introducedinto the intramedullary canal, the segments are preferably received overa rod or guidewire 32 to facilitate their mating engagement.

FIGS. 7 and 8 disclose a fourth embodiment of segments 12C for use in anintramedullary structure that is similar to the embodiments of FIGS. 4and 5. However, the segments 12C have a more elaborate interlockingconfiguration of the tabs, prongs and detents.

FIGS. 9 and 10 illustrate a fifth embodiment of segments 12D for anintramedullary structure in accordance with the present disclosure. Themale end 22D of the segment presents a plurality of longitudinal splinesthat provide a cross-section similar in appearance to a gear. The femaleend 24D has a complementarily gear shape and includes a concentric ring34 that provides a close fit with the inside diameter of the male end22D. As can be appreciated, this configuration also provides forinterfitting segments that are not rotatable with respect to each other.

FIGS. 11 and 12 illustrate a sixth embodiment of segments 12E for use inan intramedullary structure according to the present disclosure. In oneembodiment the segments 12E are generally cylindrical in configurationwith complementary interfitting tabs 30E on their male and female ends22E, 24E. The segments 12E also contain a number of spaced, longitudinalthroughbores 36 in the walls of the segments (four such throughbores 36are shown in FIGS. 11 and 12). In one embodiment the throughbores 36receive elongated peripheral rods 38 that provide the assembledintramedullary structure with additional rigidity and strength. In oneembodiment the throughbores 36 receive guide wires or guide mechanismsto help direct a distal end of the intramedullary structure duringinsertion.

With reference to FIG. 13, a further embodiment of a segmentedintramedullary structure 10 is shown. In one embodiment the segmentedintramedullary structure 10 is a hinged structure 62. The hingedstructure 62 comprises a plurality of segments 64 that are joined toeach other by a hinge member 66. The hinge member 66 permits thesegments 64 to pivot with respect to each other to facilitateintroduction of the structure into the intramedullary nail through anangled access hole.

In various embodiments segmented intramedullary structures 10 can bebent into a curvature for insertion into an access hole to avoiddamaging articulating surfaces, joints, or other tissue structures at ornear the ends of a long bone. Instead of introducing a rigid nail,embodiments of the segmented intramedullary structures can be insertedin less-invasive access points, which can result in less tissue damageand an easier surgical process for insertion or removal of theintramedullary structure. The various curvatures that are contemplatedcan vary depending on the type of bone being repaired, but can varydepending on size of the bone, tissue anatomy around the access site,retrograde access, antegrade access, and other potential considerations.For one non-limiting example, an access curvature of the intramedullarystructure configured for a humerus can be roughly 80 mm, in the generalrange of 60-100 mm, and/or in the general range of 20-200 mm. For otherbones, the curvature can be larger or smaller, again depending onfactors such as bone size. As shown in FIG. 13 one embodiment of theintramedullary structure 10 is made of a single cylindrical member withthe V-shaped notches cut out at regular intervals along the length ofthe structure 62, the material from which the cylindrical member is madeproviding a “living hinge” between the adjacent segments at the apex ofeach notch. In one embodiment, once the intramedullary structure 10 isinserted into the intramedullary canal, bone cement is introduced tokeep the intramedullary structure straight and provide furtherstructural integrity.

FIGS. 14-22 schematically illustrate the insertion of an embodiment of asegmented intramedullary structure 10 into the intramedullary canal 40of a long bone 42. In one non-limiting embodiment the long bone 42 is ahumerus. In another non-limiting embodiment the long bone is a tibia. Inother embodiments, the long bone 42 can be any long bone, such as butnot limited to a radius, ulna, femur, fibula, phalange, or other bone.

With reference to FIG. 14, a long bone 42 is shown having a fracture 44intermediate it's proximal and distal ends or regions. In one embodimentan access hole 46 is percutaneously made into the intramedullary canal40 at the proximal end of the intramedullary canal 40 at an angleoblique to the axis or centerline of the long bone, and preferably at anangle of approximately 30 degrees with respect to the axis of the longbone. In other embodiments the angle can be in the range of 10-90degrees with respect to the longitudinal axis of the long bone. Invarious embodiments an access hole 46 can be made in the proximal end,proximal region, intermediate region, distal region, or distal end ofthe intramedullary canal 40. In one embodiment an access hole 46 can bemade for retrograde insertion of a segmented intramedullary structure 10into the bone. The access hole 46 is of a diameter to accommodate theintroduction of the individual segments 12 that comprise theintramedullary structure. In one embodiment the access hole 46 isapproximately 10 mm in diameter, but other diameters are contemplateddepending on the size of the embodiment of the intramedullary structurebeing used. In one embodiment, after the access hole 46 is made, a guidewire or cable 32 is inserted there through and advanced into theintramedullary canal 40 and across the fracture site 44 to the distalend of the intramedullary canal 40.

Turning to FIG. 15, a second step of one embodiment is shown in which afirst or distal-most segment 12 is threaded over the guidewire andadvanced through the percutaneous access hole 46 into the intramedullarycanal 40. In one embodiment as shown in FIG. 16, the segment 12 isforced through the access hole 46 and advanced along the guidewire 32 bymeans of an inserter 48 that also fits over the guidewire 32. Theinserter 48 has a slotted hammer 50 associated therewith to impartadditional force to the segment 12 as it is advanced into theintramedullary canal 40.

In one embodiment as reflected in reference to FIG. 17, once the segment12 is positioned within the intramedullary canal 40, it is advancedalong the guidewire 32 to the distal end of the IM canal 40 using aflexible push rod 52. The steps of inserting a segment 12 over theguidewire and advancing it distally along the guidewire, shown in FIGS.15-17, can be repeated until an intramedullary structure of the desiredlength is created. With reference to the embodiment illustrated in FIG.18, the segmented intramedullary structure 10 has thirteen segments.Therefore the steps of FIGS. 15-17 are repeated twelve times. Othernumbers of segments can be used. In one embodiment the doctor can add orsubtract one or more segments during the insertion process.Modifications to the overall segment structure can be made and changedduring, or in the midst of a device implantation.

With reference to FIG. 19, in one embodiment the segmentedintramedullary structure 10 is secured to the distal end of the IMcanal. In one embodiment the distal-most and proximal-most segmentsinclude one or more throughbores for receiving bone screws, or lockingbolts 54. In one embodiment locking bolts 54 are introducedpercutaneously and are advanced through bores in the distal-most andproximal-most segments, using fluoroscopy for guidance. In theillustrated method, the guidewire 32 is left in place. However, if thesegments comprising the IM nail positively interlock, the guidewire 32may be removed after all the segments comprising the IM nail areinterconnected. With reference to FIG. 20, a locking nut 56 is insertedover the guidewire 32 and into the proximal-most segment, a flexibledriver 58 being used to tighten the nut 56 to a prescribed torque. Inone embodiment the exposed portion of the guidewire 32 is then cut off(see FIG. 21) and in one embodiment percutaneous locking bolts 60 areused to secure the proximal-most segment in place (see FIG. 22). Meansother than locking bolts, fixation screws, or other fasteners may beused to secure the intramedullary structure in place in theintramedullary canal, including but not limited to a bone cement orother hardenable surgical fluid, or radially expandable elements.

With reference to FIGS. 23-38, a further embodiment of a segmentedintramedullary system, generally designated 100, is disclosed. Thesystem 100 comprises three basic components: an implantable segmentedintramedullary fracture fixation device structure 102 (which can be thesame or similar to any embodiment of a segmented intramedullarystructure 10), a proximal fixation screw guide-interface 104, and acable tensioner assembly 200.

With reference to FIGS. 24-26, one embodiment of an implantable fixationstructure 102 comprises a plurality of substantially identical,inter-fitting intermediate segments 108, (nine shown), a proximal endsegment 110 having a plurality of holes or throughbores 112 adapted toreceive fixation screws, and a radially-expandable distal end segment114. A cable 116 is secured to the distal end segment that extendsthrough the implantable structure beyond the proximal end segment 110and through the cable tensioner 200 to apply a compressive force to thesegments so as to result in a rigid implant. Each of the segments 108,110 proximal to the distal end has an open interior to permit thetensioning cable 116 to pass there through and to allow the segments toslide along the cable 116 during insertion into the intramedullarycanal.

In one embodiment the proximal end segment 110 and the intermediatesegments 108 are pre-assembled, with the various segments hingedlysecured to each other. In one embodiment, in order to facilitateinsertion of the fixation structure 102 into the head of a long bone,where the entry point for the implant is offset from the axis of thelong bone, the various segments 108, 110 of the implantable structureare configured to be relatively moveable only axially and laterally in asingle plane. To this end, and with reference to FIGS. 26, 28 and 29,the intermediate segments 108 have inter-fitting male and femaleportions, 118 and 120, respectively, that comprise three substantiallyplanar faces (118 a, 118 b and 118 c for the male portion, and 120 a,120 b and 120 c for the female portion). The faces 118 a, 120 a aregenerally parallel to faces 118 c, 120 c, respectively, while the faces118 b and 120 b are generally perpendicular to the faces 118 a, 118 band 120 a, 120 b, respectively. A fourth face 118 d, 120 d is obliquelyoriented relative to the longitudinal axis of the segment. Adjacentsurfaces are joined by an arcuate surface. The three planar surfacesensure that the assembled structure is flexible substantially only in aplane substantially parallel to the parallel faces of the male andfemale portions of the segments.

Experience has shown that when members with smooth or regular tapered orconical surfaces nest, there can be a tendency for the tapered surfacesto lock together. This, of course, would be disadvantageous in thepresent structure when trying to insert or remove the structure in itsnon-rigid state, as it would result in a reduced flexibility of theimplantable structure required for insertion into and removal from theintramedullary canal. Accordingly, in one embodiment theobliquely-oriented surfaces 118 d, 120 d of the male and female portions118, 120 of the segments 108 are formed with a series of steps 122having surfaces that are substantially parallel to the axis of thesegment. This ensures that if tension is not applied to the cable 116,and the fixation structure 102 is not under compression, the matingportions of the segments freely slide apart.

In one embodiment the various segments 108, 110 of the structure aresecured to each other in a manner that permits limited axial movementrelative to the adjacent segments, and ensures the proper orientation ofthe faces of the male portion of a segment with the female portion ofthe adjacent segment. In one embodiment, the limited axial movement canbe in the range of 1 mm to 5 mm. In the structure of one embodiment,this is accomplished by providing the female portion 120 of the segmentwith a pin 124 (best seen in FIG. 28) lying in a plane perpendicular tothat in which the assembled implant flexes. The pin 124 extends throughthe open interior of the female portion 120 of its associated segmentand is captured in an axially-oriented, elongated slot 126 in the maleportion 118 of the proximally adjacent segment. As seen in the drawings,the slot 126 is wider at the distal end than at the proximal end,providing for greater flexibility of the expanded implantable structure.Of course, the pin could be carried by the male portion 118 of thesegment and ride in a slot in the female portion 120 to achieve the sameor similar result.

In one embodiment the proximal end segment 110 has an open interior forpassage of the tensioning cable and comprises two sections: an arcuatesection 128 and a mating section 130, the latter having a male portion118 as described above for seating in the female portion 120 of theimmediately distal intermediate segment. In one embodiment, to allow forfixation of the proximal end of the implantable structure to the bone,the arcuate segment includes one or more throughbores 112 (three shown)oriented generally perpendicular to the axis of the implantable fixationstructure 102 for the receipt of bone screws (not shown). Thethroughbores 112 are located so as to not intersect the open interior ofthe arcuate section, thus ensuring that the tensioning cable 116 is notcontacted by the fixation screws. In one embodiment, throughbores 112can be configured for insertion into a left-sided bone, a right-sidedbone, or for both sides. For example, throughbores 112 can be configuredfor insertion into a right humerus, a left humerus, or either humerus,with throughbores 112 oriented in light of anatomy or access.

In one embodiment the proximal end of the arcuate section 128 isconfigured to receive a two-part distal collet assembly 132 (FIGS. 35and 38) for locking the tensioning cable 116 (as will be described ingreater detail below) and to also seat the screw guide interface 104 ina predetermined orientation.

As described in connection with the prior embodiments, the distalportion of the implantable structure can be configured to be fixed tothe bone by bone screws, bone cement, or other fixing means. In oneembodiment the fixation of the implantable structure to the distalportion of the long bone is accomplished by having the distal-mostsegment 140 be radially expandable so as to engage the surface of theintramedullary canal. To this end, and with reference to FIGS. 27, 32and 33, in some embodiments the distal segment 140 comprises anexpanding member 142 that receives a wedge member 144 on the interiorthereof. The wedge member 144 is secured to the distal end of thetensioning cable so that as tension is placed on the cable 116, thewedge member 144 is moved proximally into the expanding member 142 tocause the expanding member 142 to radially expand into engagement withthe surface of the intramedullary canal.

The illustrated embodiments of an expander 142 in FIGS. 27, 32 and 33can comprise an upper collar portion 146 from which extend in cantileverfashion a plurality of legs 148. In one embodiment the plurality of legs148 are evenly radially-spaced legs 148 (four shown). In one embodimentin its undeformed state, the expander 142 has a radial dimension nogreater than that of the other segments 108, 110 of the implantablefixation structure 102 in order to facilitate insertion into theintramedullary canal. The wedge member 144 is generally conical inshape, and has elongated grooves 150 in its surface for seating the legs148 of the expander 142. Preferably, the grooves 150 have across-sectional shape that is complimentary to the inner surfaces of thelegs 148.

In order to enhance the anchoring of the expander in the intramedullarycanal, the outer surfaces of the legs may be formed with structuresdesigned to more easily penetrate into the boney surface of theintramedullary canal. Such structures may take the form of points or anarrow edge or blade-like structure. In the illustrated embodiment, theouter surface of each leg is provided with a continuous raised spine152. In one embodiment the spines 152 have a wavy or zig-zagconfiguration, which provides resistance to both axial and rotationalmovement of the embedded expander 142.

As noted above, in one embodiment, the proximal end segment 110 includesone, two, three, four or more throughbores 112 for receiving bone screwsto secure the proximal end of the implant 102 in position. In oneembodiment, multiple optional throughbores 112 can be configured for theoptional use of bone screws for particular orientations or anatomy. Tofacilitate the placement of the screws, in one embodiment the proximalsegment 110 is adapted to mount a screw guide interface 104. In variousembodiments, the screw guide interface 104 can be configured to guidethe one, two, three, four or more screws in proper orientation. In theillustrated embodiment, three screws are being used for illustrativepurposes. In one embodiment a collet is adapted to mount a screw guideinterface 104. As seen in the embodiments in FIGS. 34 and 35, the screwguide 104 comprises a pair of depending arms 154, 156, with a first arm154 mounting a pair of guide tubes 158, 160 and a second arm 156mounting a single guide tube 162. When the screw guide interface 104 issecured to the proximal end segment 110 of the implant 102, the guidetubes 158, 160, 162 are aligned with the throughbores 112. The upperends of the arms 154, 156 are joined together, with a tubular-shapedsegment 164 depending downwardly from the juncture of the arms 154, 156.The lower end of the tubular-segment 164 and the upper end of theproximal segment 110 are configured so that the screw guide interface104 seats on the proximal segment 110 in proper orientation, with thescrew guide tubes 156, 160, 162 aligned with their intended throughbores112. Once properly seated, the screw guide interface 104 is secured tothe implant by an insertion guide 166. The insertion guide 166 has anenlarged gripping surface 168 and a depending tubular section 170. Thegripping surface 168 of the insertion guide 166 seats in a recessedportion of the screw guide interface 104, with the tubular section 170of the insertion guide 166 extending through the tubular segment 164 ofthe screw guide interface 104 so as to be received in the proximal endof the proximal segment 110 of the implant 102. The distal end of thetubular section 170 of the insertion guide 166 is externally threaded,while the interior surface of the proximal end of the proximal segment110 is internally threaded. Thus, the insertion guide 166 can be screwedinto the proximal end segment 110 to secure the screw guide interface104 in position on the implantable fixation device 102.

A tensioner tool assembly may be utilized to regulate and/or locktension on the cable in the fixation device. In one embodiment thetensioner tool assembly 200 may comprise a cable, a locking feature, atensioner, and a locking mechanism actuator. Referring to FIG. 36, aperspective view of one embodiment of a tensioner tool assembly 200 isshown. It is appreciated that the tensioner tool assembly 200 may beused to provide and regulate tension to a cable, cord, tether or otherflexible member connected to a segmented intramedullary fracturefixation device as set forth above, or may be used to provide andregulate tension for other implants, devices or systems. When used witha segmented intramedullary fracture fixation device such as segmentedintramedullary structure 10 or fixation device 102, the tensioner toolassembly 200 may be guided over the cable 116 (connected to andextending from the fixation device, not shown), and releasably attachedto the proximal end of the device. In one embodiment a proximal colletscrew, a tensioner and a distal collet assembly comprising a cablecollet screw may be actuated in sequence to attain and lock down thetension on the cable in the fixation device at a preferred level. Thetensioner tool assembly 200 may then be removed, and the cable extendingoutside of the fixation device 200 may be cut off, while the cableinside the fixation device remains at the preferred tension.

In one embodiment the tensioner tool assembly 200 comprises a proximalcollet 210 which engages within a threaded shaft 220. Distal to theproximal collet is a threaded knob 240 which partially extends into ahousing 230. The housing 230 is shaped to be dockable in the insertionguide 166, which can connect to the proximal end of the fixation device.A collet driver 250 is captured within the housing 230 and is configuredto be rotatable within the housing 230. Within the connection betweenthe insertion guide 166 and the fixation device is the distal colletassembly 132. A cable bore 202 extends longitudinally along a straightpath within the entire length of the assembly 200.

In one embodiment, when connecting the tensioner tool assembly 200 tothe fixation device 102, first the insertion guide 166 may be guidedover the cable 116 and attached to the fixation device 102, and then theremainder of the tensioner tool assembly 200 guided over the cable 116and docked via the housing 230 within the insertion guide 166.Alternately, the tensioner tool assembly 200 may first be docked to theinsertion guide 166, and the entire assembly then guided over the cable116 and attached to the fixation device 102. Threads or other couplingfeatures may provide an interface to dock the housing 230 to theinsertion guide 166.

Referring to FIG. 37, a longitudinal partial cross-sectional view of thetensioner tool assembly 200 is shown. For clarity in distinguishing theparts of the tensioner tool assembly, the cable is not shown. The cablebore 202 is seen extending the length of the assembly 200 along astraight path. The threaded knob 240 has an internally threaded lumen242 through which the threaded shaft 220 extends. The threaded shaft 220extends through the lumen 242 from the proximal end of the threaded knob240, and into the housing 230. A crossbar 232, through which the shaft220 passes, may provide an anti-rotation feature preventing rotation ofthe shaft. A retaining feature 221 may retain the distal end of threadedshaft within the housing 230, preventing accidental withdrawal of thethreaded shaft 220 from the lumen 242. The threaded shaft 220 hasexternal threads 222 which extend for a distance along its exterior. Atthe proximal end of the threaded shaft 220 is a short section ofinternal threads 224, and distal to the internal threads 224 is achamber 226 with a tapered wall 228.

The proximal collet 210 fits into the proximal end of the threaded shaft220. External threads 212 engage with the internal threads 224 on thethreaded shaft to hold the collet 210. A plurality of flexible fingers214 extend distally from the collet 210, into the chamber 226. Aspreviously described, the tensioner tool assembly 200 is guided over thecable 116 (not shown), and the cable extends through the cable bore 202and out the proximal end of the proximal collet 210. The proximal collet210 is a locking feature which may be locked onto a location on thecable by screwing the proximal collet 210 into the threaded shaft 220.As the collet 210 is screwed in, the fingers 214 advance distally intothe chamber 226. As the fingers 214 bias against the tapered wall 228,they are urged together, engaging and constricting the cable, until thecable is securely gripped. As the fingers 214 engage the cable, they maysubstantially circumferentially surround the cable. In this position,the cable is locked and prevented from being pulled in either direction.However, the cable can again be freely moved by simply unscrewing collet210 from within threaded shaft 220 so that fingers 214 are able tofreely, outwardly flex and disengage from the cable. In one embodimentit is noted that in the locking process, the cable 116 remains orientedsubstantially along a straight path within the assembly 200 and is notbent, curved, crimped or severed.

Once the cable is locked the tensioner may be actuated to regulatetension to the cable. In one embodiment the tensioner may comprise thehousing 230, the threaded knob 240, the threaded shaft 220, the crossbar232, and the retaining feature 221. The threaded knob 240 may beactuated by turning it to provide tension to the cable. As the knob 240is turned, internal threads 244 engage with the external threads 222 onthe threaded shaft 220, and the knob 240 moves distally while thethreaded shaft 220 moves proximally as the rotational motion istranslated into linear motion. Since the cable is connected to thefixation device at a first location at the distal end segment of thefixation device, and locked within the collet 210 within the shaft 220at a second location, moving the shaft 220 proximally moves the collet210 relative to the fixation device, putting tension on the cablebetween the first location at the fixation device and the secondlocation at the collet.

In one embodiment, as the knob 240 moves distally, a distal face 246 ofthe knob 240 pushes on a spring 248 which surrounds the threaded shaft220 in the housing 230. As the knob 240 is turned further, the spring248 is compressed between the knob distal face 246 and a lip 234 formedin the wall of the housing 230. This compression may provide a measureof the amount of force applied to the knob. Indicator markings 247(shown in FIG. 36) may be present on the outside of a distal wall 249 ofthe threaded knob 240 to indicate a measurement. In one embodiment theindicator markings 247 indicate the amount of force as the knob isturned. In one embodiment the indicator markings 247 indicate the amountof axial movement by the cable with respect to the distal end of thefixation device in terms of length as the knob 246 is turned. The knob246 is actuated by turning either direction, increasing or decreasingthe tension, until a preferred level of tension is reached.

Referring to FIG. 38, a partial cross-sectional view of a cable 116passing through the distal collet assembly 132, which is surrounded by aconnection between a portion of the insertion guide 166 and a proximalend segment 110 of the fixation device 102, is shown. For clarity, thecable 116 is not shown in cross-section, but a stylized outer surface ofthe cable 116 is shown. External connection threads 262 on the insertionguide 166 engage with internal connection threads 264 on the fixationdevice 102 to hold the insertion guide 166 in a fixed position relativeto the fixation device 102. A cable collet anchor 272 fits within theproximal end 110 of the fixation device 102 and extends for a shortdistance into the insertion guide 166. The cable collet anchor 272 maybe integrally formed in, welded, bonded, press-fit or otherwiseconnected to the fixation device 102. A chamber 274 having a taperedwall 276 is in a distal end of the cable collet anchor 272, and theproximal end of the cable collet anchor has internal collet threads 278.

A cable collet screw 280 fits within the cable collet anchor 272, heldin place by external collet threads 282 which engage with the internalcollet threads 278. At a proximal end of the cable collet screw 280, ashaped inner wall 286 surrounds the cable bore 202. A plurality offlexible fingers 284 extend distally, into the chamber 274. In oneembodiment, together the cable collet screw 280 and the cable colletanchor 272 form a locking mechanism.

Extending distally through the insertion guide 166 is a driver shaft 252of the collet driver 250. As seen in FIG. 38, the collet driver 250 iscaptured within the tensioner, but operates independently from thetensioner. A working end 254 of the driver shaft 252 is shaped to matewith the shaped inner wall 286 of the cable collet screw 280. In variousembodiments the working end 254 may be shaped as a hexagon or any othershape configured to mate with the cable collet screw. In variousembodiments, the working end 254 of the driver shaft 252 can beconfigured to operate with any shaped interface on the cable colletscrew 280.

In one embodiment, after the cable 116 has been tensioned as set forthabove, the collet driver 250 is actuated to actuate the lockingmechanism which includes the cable collet screw 280 and anchor 272. Tolock the position of the tensioned cable 116 at a third location, whichis relative to the fixation device 102, the cable collet screw 280 istightened. To tighten the cable collet screw 280, the collet driver 250is turned, turning the collet driver shaft 252. The working end 254mates with the shaped inner wall 286 of the cable collet screw, andconsequently the cable collet screw 280 is turned. As the collet screw280 turns and advances within the anchor 272, the fingers 284 advanceinto the chamber 274. As the collet fingers 284 bias against the taperedwall 276, they are urged together, gripping the cable 116 and lockingits position relative to the fixation device 102. In this position,cable 116 is prevented from being pulled in either direction. However,cable 116 can again be freely moved by simply unscrewing collet screw280 from within the anchor 272 so that fingers 284 are able to freely,outwardly flex.

In one embodiment, once the cable 116 is locked in the cable colletscrew 280, the tension on the cable relative to the fixation device 102is fixed. The proximal collet 210 may be unscrewed, releasing its gripon the cable 116. The housing 230 may be undocked from the insertionguide 166, allowing removal of the tensioner tool 200 from the insertionguide 166. The insertion guide may then be unscrewed and removed fromthe fixation device 102, leaving the cable 116 locked in the cablecollet screw 280. Alternately, in one embodiment, the housing 230 mayremain docked within the insertion guide 166, and the insertion guide166 may be uncoupled from the fixation device 102, bringing the dockedtensioner tool 200 with it. After both the insertion guide and tensionertool are removed, the cable 116 extending proximally from the distalcollet screw 280 may be cut to a preferred length proximal to the cablecollet screw 280.

Various embodiments of intramedullary structures as disclosed herein maylist various parameters, such as sizes, lengths, diameters, widths,curvatures and geometry that can conform to or be implanted based onvarious parameters of bones and of structures in which embodiments ofthe devices may be configured to be implanted. Listings provide someexamples, but should not be read to limit the disclosure to thosespecific dimensions or characteristics. For example, the number ofsegments used in a device and its various size and shape and featurecharacteristics can vary depending on parameters of the bone and/orpatient, the type of fracture, and other factors. Embodiments of theintramedullary structures are scalable. For example, some non-limitingdiameters (or widths) of certain embodiments could range from about 5 mm(for such uses as pediatric bones, or adult clavicle, radius) to about18 mm (for such uses as an adult femur). Embodiments of lengths couldvery from a few inches to 800 mm in a knee fusion nail (from ankle tohip). Various embodiments may be configured for implantation in any longbone anatomies, including but not limited to a femur, tibia, fibular,humerus, ulna, radius, clavicle, metatarsals, metacarpals, and others.

In one embodiment a segmented intramedullary structure 300 comprisingsegments 310 is similar or has features the same or similar to thefeatures of intramedullary structure 10 with segments 12 and/orimplantable segmented intramedullary fracture fixation device structure102 with segments 110, 108 and 114, or any other implant with segmentsdescribed herein. In one embodiment a segmented intramedullary structure300 comprises a number of primary components: a segment construct, abraided cable, a stiffening tube for the cable, a collet, an end cap andbone screws. In one embodiment the segment construct contains a seriesof segments 310 with complementary interfaces between the segments 310.In various embodiments the complementary interfaces can comprisecomplementary surfaces, complimentarily-shaped features, mating male andfemale portions, nested features, paired geometries, and the like whichcan interface a proximal, medial, intermediate, middle, or distalportion, area, or end of the respective segments. In one embodiment asegment 310 has a first interface and a complementarily-shaped secondend interface, so that the first interface of a segment 310cooperatively engages the second interface of an adjacent segment 310.In one embodiment segments 310 have a male geometry at one end, a femalegeometry on the opposite end and a hole or channel substantiallyextending along the linear axis. In various embodiments the segmentconstruct can contain straight segments and/or transition segments. Inone embodiment the individual segments are rigid. In one optionalembodiment the individual segments are flexible. In one embodimenttransition segments increase or decrease in width or diameter along thelength of the transition segment. One or more transition segments can beused to transition the width, size, diameter, or thickness of thesegment construct between proximal, intermediate, and/or distal ends orregions. In one embodiment the male geometry of the links comprises anelliptical shaped cone or taper which mates with a similar ellipticaltaper on the female geometry of the adjacent link. In one embodiment theindividual links are connected together with a snap ring so that themale geometry resides within the female geometry.

In various embodiments the complementary interfaces of the individuallinks or segments 310 can be configured to allow movement of segments310 with respect to each other between two, three, or moreconfigurations. In one embodiment the segments 310 can be distractedfrom each other, in a distracted configuration 308 in which two or moresegments 310 are at least axially moved away from each other. See FIG.58B. In one embodiment distracted segments 310 can still be attached toeach other, but farther apart. In one embodiment segments 310 areremovably attachable from each other to prevent segments 310 fromcompletely separating from each other when distracted. In one embodimentsegments 310 are locked to each other to prevent segments 310 fromcompletely separating from each other when distracted. In one embodimentsegments 310 are permanently attached to each other to prevent segments310 from completely separating from each other when distracted. In oneembodiment the segments 310 can have an axial displacement length 304,indicating the axial distance along a longitudinal axis of one or bothadjacent segments 310 that the adjacent segments 310 can move withrespect to each other while still connected to each other. In variousnon-limiting embodiments, the axial displacement length 304 betweenadjacent segments can be anywhere in a range of 2-10 mm, including butnot limited to roughly 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, 9 mmand 10 mm. In one embodiment, the overall length of a segmentedintramedullary structure 300 increases as segments are distracted withrespect to each other with segments 310 in one or more respectivedistracted configurations 308. In one embodiment a segmentedintramedullary structure 300 can maintain an overall configuration, suchas a straight configuration, while distracted. In one embodiment asegmented intramedullary structure 300 can be configured to bend or flexor have segments 310 that move rotationally with respect to each otherin a distracted configuration 308.

In one embodiment the segments 310 can be flexed, rotated or bent withrespect to each other, in a bent configuration 307 in which two or moresegments 310 are at least radially rotated with respect to each other.See FIG. 58C. In one embodiment the segments 310 can have a rotationaldisplacement angle 305, indicating the angle between the respectivelongitudinal axes of the adjacent segments 310 that the adjacentsegments 310 can move with respect to each other while still connectedto each other. In various non-limiting embodiments, the rotationaldisplacement angle can be up to 4, 5, 10, 15, 20, 30, 45 or 90 degrees.In one embodiment the segments 310 are distracted in order to bend withrespect to each other. In one embodiment, pushing segments 310 togetheror compressing them causes the segments 310 to move towards each otherin to a compressed configuration. In one embodiment pushing segments 310together or compressing them while the segments 310 are more than aspecific angle with respect to each other temporarily locks the segments310 in a bent configuration 307, allowing the segments 310 to be pushedor to transmit an axial load without collapsing out of its bentconfiguration 307. In one embodiment segments 310 are configured toremain in a first bent configuration 307 a while adjacent segments 310are at least a first rotational displacement angle 305 a. In oneembodiment segments 310 are configured to move out of a first bentconfiguration 307 a while adjacent segments 310 are less than the firstrotational displacement angle 305 a. For example, in one embodiment theoverall shape of a segmented intramedullary structure 300 can be bent,flexed, or curved with two or more of its segments 310 rotated withrespect to each other with an angle of at least a first rotationaldisplacement angle 305 a. When the segments 310 are at an angle of atleast the first rotational displacement angle 305 a, the curvedsegmented intramedullary structure 300 can be pushed or pulled through ahole in tissue such as skin or bone while still curved. Once the anglebetween segments 310 reduces to an angle less than the first rotationaldisplacement angle 305 a, the segments 310 can move out of the firstbent configuration 307 a. In various embodiments, multiple rotationaldisplacement angles 305 can determine multiple bent configurations 307.

In various embodiments, a compressed configuration may have an overallshape for the adjacent segments in a curved or straight configuration.In one embodiment two or more segments 310 can be compressed againsteach other, in a compressed configuration 306 in which two or moresegments 310 are configured to be aligned with respect to each otherwith a reduced axial displacement and a reduced rotational displacementwith respect to each other. See FIG. 58D. In one embodiment segments 310are in a straightened configuration when compressed. In one embodimentthe axial displacement length between segments 310 is substantially zerowhen in the compressed configuration 306. In one embodiment therotational displacement angle 305 between segments 310 is substantiallyzero when in the compressed configuration 306. The measurement ofvarious lengths and angles may depend on the application, size of thesegments, number of segments, size of bone for implantation, approach(retrograde, etc.), or other factors. In various embodiments,interaction between features on the interior and/or exterior surfaces ofadjacent segments 310 can be configured to adjust or determine the axialdistraction range of motion and/or rotational bending range of motion ofthe segments 310 with respect to each other.

In one embodiment the individual links can be partially separated toprovide flexibility but will become substantially rigid once theindividual links are compressed together. In one embodiment theindividual links can be partially separated to provide a first level offlexibility but will become a different, second level of flexibilityonce the individual links are compressed together. In one embodiment thesecond level of flexibility is less than the first level of flexibility.In one embodiment an attachment structure prevents the segments frombecoming permanently separated, thus aiding with device removal orextraction if necessary. In various non-limiting embodiments, theattachment structure can include a pin, slot, snap fit, threads, or asnap ring. In one embodiment, during the surgical procedure, the segmentconstruct will be inserted into the bone canal over the cable and cablestiffening tube. Tension is applied to the cable in order to compressthe tapered male geometry and tapered female geometry together to form arigid nail. The cable tension will be held by a collet that is threadedinto the proximal end of the segment construct. In one embodiment, thedevice is intended to function as a flexible intramedullary nail duringthe surgical procedure but will become rigid once the cable is tensionedand the segment construct is compressed. In one embodiment the rigiddevice is secured to the bone with bone screws that are inserted throughthe proximal and distal segments. In one embodiment, two bone screws areused in the proximal segment and two bone screws are used in the distalsegment. In one embodiment, an end cap is threaded into the proximalsegment after the device is secured in order to prevent bone in-growtharound the cable collet. Once the end cap is in place the cable will becut flush with the end cap.

In one embodiment, a segmented intramedullary structure is configuredfor insertion in a humeral bone. In one embodiment the bone screws are4.0 mm in diameter. In one embodiment of a humeral segmentedintramedullary structure the hole, or channel, is 2.25 mm in diameter.In various embodiments the humeral segmented intramedullary structurecan be provided in various diameters, such as (but not limited to) 8 mm,9 mm or 10 mm. In various embodiments the humeral segmentedintramedullary structure can be provided in various lengths, such as(but not limited to) 170 mm, 187 mm, 205 mm, 222 mm, 240 mm, 257 mm, 275mm or 292 mm. In various embodiments the humeral stiffening tube can beprovided in various lengths which can correspond to the increasinglength of the segmented intramedullary structure. In various embodimentsthe humeral end cap can be provided in various lengths, such as (but notlimited to) 12.7 mm, 17.7 mm or 22.7 mm. In various embodiments thehumeral bone screws can have a 4.0 mm diameter and any of the followingnon-limiting examples of lengths: 16 mm, 18 mm, 20 mm, 22 mm, 24 mm, 26mm, 28 mm, 30 mm, 32 mm, 34 mm, 36 mm, 38 mm, 40 mm, 42 mm or 46 mm. Invarious embodiments, the cable length can be configured to work with anydevice, depending on device length. In one embodiment the cable has apre-cut length of 914 mm.

In various embodiments a segmented intramedullary structure isconfigured for insertion in bones of varying shapes and/or sizes. Invarious embodiments, the nominal diameter of a segmented intramedullarystructure can be 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15 mm orother dimensions. In various embodiments, the diameter of a proximal endsegment of a segmented intramedullary structure can be 11 mm, 14 mm, 16mm or other dimension. In various embodiments, transition segments canrange in width or diameter from 8 to 9 mm, 9 to 10 mm, 10 to 11 mm, 11to 12 mm, 12 to 13 mm, 13 to 14 mm, 14 to 15 mm, 15 to 16 mm, or othertransition sizes. In various embodiments, straight segments can have awidth or diameter of 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15mm, or other sizes. In one embodiment, a distal segment can be tapered.In various embodiments a distal segment can be tapered distally by 1 mm,0.5 mm or other values. In various embodiments, a segmentedintramedullary structure can built to varying lengths, comprisingvarying numbers of segments (transition, straight, or otherwise) asneeded. In various embodiments, lengths can be about 170 mm to about 500mm.

Secondary Compression

Various embodiments of segmented intramedullary structures as disclosedherein allow the surgeon to compress the fracture site after placing thesegmented intramedullary structure in the bone and fixating the proximaland distal bone segments. See FIGS. 39A-B and FIGS. 40A-B, whichillustrate an embodiment of a segmented intramedullary structure 300before and after secondary compression in a bone 42. Segmentedintramedullary structure 300 can have the same or similar aspects assegmented intramedullary structure 10 and implantable segmentedintramedullary fracture fixation device structure 102. Bone 42 can beany type of bone, such as, but not limited to, a long bone. FIGS. 39Aand 40A illustrate one embodiment of a segmented intramedullarystructure 300 with the fractured long bone 42 attached superiorly andinferiorly to the fracture site to the segmented intramedullarystructure 300. After this superior and inferior anchoring or attachingat a proximal and distal sites, an embodiment of the segmentedintramedullary structure 300 can have an interior cable or tensioningmechanism lock or rigidly connect the segments of the segmentedintramedullary structure 300 together, imparting a compressive loadacross the bone fracture site 44 to assist in healing the fracture 44,as shown in FIGS. 39B and 40B. This compression feature is particularlyuseful in non-load bearing bones 42 such as in the arm where even a 1 mmgap at the fracture site can prevent healing. In one embodiment, thistype of compression can be called “Secondary Compression.”

In some embodiments secondary compression may be expressed in terms ofcompressive force applied to bring bone segments together with a device.In some embodiments secondary compression may be expressed in terms ofthe tensile force applied to a tensioning mechanism to bring bonesegments together with a device. In some embodiments, secondarycompression can be described in terms of a distance, such as thedistance that bone segments are brought together in secondarycompression. In one embodiment secondary compression is expressed interms of the decrease in the decrease in axial length of the devicealong the direction of the secondary compression. In one embodiment thedistance associated with secondary compression is proportional to theamount of compressive or tensile force applied to the device. In oneembodiment segmented intramedullary structures can be configured toprovide substantially one level or one distance in secondarycompression. In one embodiment segmented intramedullary structures canbe configured to provide varying levels or ranges of secondarycompression. In one embodiment a segmented intramedullary structure canprovide a smooth, continuous transition between levels of secondarycompression. In one embodiment a segmented intramedullary structure canprovide a discrete transition between levels of secondary compression.In one embodiment a segmented intramedullary structure can provide adiscrete transition between levels of secondary compression with aratcheting action.

In one embodiment a segmented intramedullary structure can provide nosecondary compression. In various embodiments a segmented intramedullarystructure can be configured to provide a single secondary compressiondistance with a value in the range of about 1 mm to 5 mm. In variousembodiments a segmented intramedullary structure can be configured toprovide 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm of secondary compression. In oneembodiment a segmented intramedullary structure is configured to provideanywhere in the range of about 1 mm to 5 mm of secondary compression.

Studies were performed with various embodiments of the segmentedintramedullary structure confirming that secondary compression of thefracture site after the fracture has been reduced and proximal anddistal fixation is in place helps ensure that the surgeon reaches fullreduction at the fracture site. In one embodiment, an additional benefitof secondary compression is that it takes some of the load off theimplant which will help in implant longevity.

Segments

With reference to FIGS. 41A-78, further embodiments of segmentedintramedullary structures 300 with segments, generally designated 310,are disclosed. In one embodiment, segment 310 can have features similarto the various embodiments of the various other segments describedherein, such as segments 12, 108, or others. Various terms or parts mayhave features which can be the same or similar to other describedembodiments herein. In various embodiments segment 310 has a male matingsection 320 and a female mating section 330. In various embodimentssegment 310 has a channel 340 extending through a longitudinal axis ofthe segment 310.

In various embodiments, segments 310 can be subjected to secondarycompression with an elongate member 350. In various embodiments elongatemember 350 can be a wire, guide wire, pull wire, push wire, cable, rod,threaded rod, or other similar structure. In one embodiment the elongatemember is a tensioning member extending along the length of thesegmented intramedullary structure. In one embodiment elongate member350 is a tensioning rod 14, which is extended through the segment 310.In one embodiment the elongate member 350 is cable 116. In oneembodiment the elongate member 350 provides a means for holding thesegments 310 together in a generally axial, straight, straightened orcurved configuration. Although the term “straight” or “straightened” maybe used with respect to the segments, it is contemplated that segmentsmay be configured to align an assembly in a straight line, but may alsobe configured in certain embodiments to “lock” in a rigid configurationthat has a curvature or bend to the overall structure. The segments 310can be distracted from each other in order to allow bending in one ormore planes or about one or more axes.

With reference to FIGS. 41A-C, in one embodiment, a stepped segment 310a can be distracted or pulled apart axially to allow two or more steppedsegments 310 a to bend in one plane. In one embodiment a stepped segment310 a can be distracted or pulled apart axially to allow two or morestepped segments 310 a to bend about one axis. With reference to FIGS.42A-C in one embodiment, a pair of stepped segments 310 a are bent withrespect to each other. With reference to FIGS. 43A-C in one embodiment,a pair of stepped segments 310 a are in axial alignment with respect toeach other in a straightened configuration.

With reference to FIGS. 44A-E, in one embodiment a snap segment 310 bhas male mating section 320 b with a flat feature 321 b and a taperfeature 322 b and a female mating section 330 b with a flat feature 331b and a taper feature 332 b which are configured to allow bending in oneplane when at least partially distracted. In one embodiment the taperfeatures 322 b and 332 b enable easier engagement of the adjacentsegments 310 b when they are compressed together. The snap feature 323 bprovides for ease of assembly of adjacent snap segments 310 b. The snapfeature 323 b can also lock to retain adjacent snap segments 310 btogether so they do not fall apart when the assembly is distracted,moved or subjected to tensile forces. In one embodiment a snap segment310 b can be distracted or pulled apart axially to allow two or moresnap segments 310 b to bend in one plane. In one embodiment a snapsegment 310 b can be distracted or pulled apart axially to allow two ormore snap segments 310 b to bend about one axis. With reference to FIGS.45A-E in one embodiment, a pair of snap segments 310 b are bent withrespect to each other in the side view in FIGS. 45A-45B but remainstraight and distracted in the front view in FIGS. 45C-45D. In oneembodiment, segments may be distracted from one view while bent fromanother view. Although the segments are bent with respect to each other,the rotational displacement may occur substantially within one only oneplane. With reference to FIGS. 46A-E in one embodiment, a pair of snapsegments 310 b are in axial alignment with respect to each other in astraightened configuration. In one embodiment, adjacent snap segments310 b have corresponding taper features 322 b and 332 b to enable easierengagement of the snap segments 310 b when they are compressed together.The snap feature 323 b allows the segments 310 b to be assembledtogether easily and retains the snap segments 310 b together so they donot fall apart when the assembly is distracted.

With reference to FIGS. 47A-C, in one embodiment a unidirectionalsegment 310 c has a male mating section 320 c and a female matingsection 330 c and a channel 340 c. Adjacent unidirectional segments 310c can be mated together and a pin 361 (not illustrated here) is placedin a pin hole 337 to retain the unidirectional segments 310 c together.In one embodiment a step surface 324 c is slideably and/or rotationallymoveable with respect to the pin 361 allowing the pin 361 to keep thesegments 310 c from falling apart while allowing movement to actuate thesystem between straightened and bent configurations. In variousembodiments, interaction between the pin 361 and step surface 324 c canbe configured to adjust or determine the axial, bend, and/or rotationalrange of motion of the segments with respect to each other.

With reference to FIGS. 48A-C, in one embodiment a unidirectionalsegment 310 d has a male mating section 320 d and a female matingsection 330 d and a channel 340 d. In one embodiment unidirectionalsegment 310 d is similar to unidirectional segment 310 c, but is longer.In one embodiment, a slight taper on both the male and female matingsections, 320 d and 330 d respectively, keeps the parts locked togethertightly and greatly reduces play between the unidirectional segments 310d when they are assembled with a tensioned elongate member 350. Adjacentunidirectional segments 310 d can be mated together and a pin 361 (notillustrated here) is placed in a pin hole 337 to retain theunidirectional segments 310 d together. In one embodiment a step surface324 d is slideably and/or rotationally moveable with respect to the pinallowing the pin to keep the unidirectional segments 310 d from fallingapart while allowing movement to actuate the system between straightenedand bent configurations. In one embodiment, the step surface 324 d islocated in a plane perpendicular to the plane of bending, andstrengthens the assembled intramedullary structure in bending and alsoserves as a stop when the assembled intramedullary structure is bent.This allows the bent intramedullary structure to be pushed into theintramedullary canal without the unidirectional segments 310 d seating.The assembled intramedullary structure 300 d is bent by pulling theunidirectional segments 310 d apart longitudinally and then bending orrotating the unidirectional segments 310 d with respect to each other.In one embodiment the unidirectional segments 310 d are designed suchthat bending mainly occurs in one direction. With reference to FIGS.49A-C in one embodiment a pair of unidirectional segments 310 d are bentwith respect to each other. With reference to FIGS. 50A-C in oneembodiment, a pair of unidirectional segments 310 d are in axialalignment with respect to each other in a straightened configuration.

With reference to FIGS. 51A-C, in one embodiment a threaded segment 310e has a male mating section 320 e, a male threaded section 325 e, afemale mating section 330 e, a female threaded section 335 e, anarticulation chamber 333 e, and a channel 340 e. Adjacent threadedsegments 310 e can be assembled by threading the male threaded section325 e of a first threaded segment 310 e into the female threaded section335 e of a second threaded segment 310 e. In one embodiment, afterthreading the male threaded section 325 e of a first threaded segment310 e through the female threaded section 335 e of a second threadedsegment 310, the male threaded section 325 e and a portion of the malemating section 320 e can move within an articulation chamber 333 e. Invarious embodiments the articulation chamber 333 e is sized andconfigured to allow motion in one, two, three or more planes. In oneembodiment the articulation chamber 333 e is sized and configured toallow rotation between adjacent first and second segments 310 e. In oneembodiment the male threaded section 325 e and the female threadedsection 335 e is designed such that as they reach the last half (½) toquarter (¼) turn there is a small amount of interference between themale and female portions to help secure the threaded segments 310 etogether. As the adjacent threaded segments 310 e are forced past thisinterference the male threaded section 325 e drops into the articulationchamber 333 e. In one embodiment the articulation chamber 333 e is anundercut area in the female mating section 330 e of the mating part. Theadjacent threaded segments 310 e then cannot be disassembled by pullingaxially but must be unthreaded and forced past the point of interferenceagain. This feature keeps the adjacent threaded segments 310 e togetherunless they are deliberately disassembled. In one embodiment there is aslight taper on both the male mating section 320 e and female matingsection 330 e which keeps the adjacent threaded segments 310 e lockedtogether tightly and reduces or eliminates play between the adjacentthreaded segments 310 e when they are assembled with a tensionedelongate member 350.

With reference to FIGS. 52A-C, in one embodiment a threaded segment 310f has a male mating section 320 f, a male threaded section 325 f, afemale mating section 330 f, a female threaded section 335 f, anarticulation chamber 333 f, and a channel 340 f and is similar tothreaded segment 310 e but also comprises a step surface 324 f on themale mating section 320 f that allows adjacent threaded segments 310 fto bend more in one direction than another, and can also serve as a stopwhen the threaded segments 310 f of an intramedullary structure 300 fare bent. This allows the bent intramedullary structure to be pushedinto the intramedullary canal without the threaded segments 310 fseating. The assembled intramedullary structure 300 f is bent by pullingthe threaded segments 310 f apart longitudinally and then bending orrotating the threaded segments 310 f with respect to each other. In oneembodiment the threaded segments 310 f are designed such that bendingmainly occurs in one direction. With reference to FIGS. 53A-C in oneembodiment a pair of threaded segments 310 f are bent with respect toeach other. With reference to FIGS. 54A-C in one embodiment, a pair ofthreaded segments 310 f are in axial alignment with respect to eachother in a straightened configuration.

In one embodiment a snap ring segment 310 g of a segmentedintramedullary structure 300 can be configured to connect with anadjacent snap ring segment 310 g with a snap ring 323 g. In variousembodiments, the snap ring 323 g is a separate and moveable componentfrom the two adjacent snap ring segments 310 g, allowing a range ofrelative movement between the two adjacent snap ring segments 310 g. Inone embodiment the snap ring 323 g is moveable with respect to both theadjacent snap ring segments 310 g. The snap ring segment 310 g in FIGS.55A-E is illustrated without a snap ring 323 g. For some illustrationsof an embodiment of a snap ring 323 g, see FIGS. 56B, 56D, 57B and 57D.

In one embodiment the snap ring segment 310 g includes a distal end 326,a proximal end 336, a male mating section 320 g, a female mating section330 g, and a central lumen or channel 340 g extending through alongitudinal axis of the snap ring segment 310 g. In the illustratedembodiment in FIGS. 55A-E, the male mating section 320 g is at thedistal end 326 and the female mating section 330 g is at the proximalend 336. In another embodiment, the male mating section 320 g can be atthe proximal end 336 and the female mating section 330 g is at thedistal end 326. The external surfaces of the male mating section 320 gare configured to interface with the internal surfaces of the femalemating section 330 g, along the channel 340 g.

In one embodiment a snap segment 310 g has male mating section 320 gwith a flat feature 321 g and a taper feature 322 g and a female matingsection 330 g with a flat feature 331 g and a taper feature 332 g whichare configured to allow bending in one plane when at least partiallydistracted. In one embodiment a snap ring segment 310 g can have one ormore flat features 321 g, 331 g along one or more surfaces to limit orsubstantially restrict relative lateral motion between adjacent snapring segments 310 g to relative motion between the segments 310 g in asingle plane or an axis substantially parallel to the flat feature 321g, 331 g. In various embodiments, a maximum rotational displacementangle 305 (see FIG. 56B) along a flat feature 321 g in a compressedconfiguration 306 is no more than about zero degrees, 0.5 degrees, 1degree, 2 degrees, 3 degrees, or 5 degrees or less. In variousembodiments, a maximum rotational displacement angle 305 along a flatfeature 321 g in a distracted configuration 308 or a bent configuration307 can be no more than about 0.5 degrees, 1 degree, 5 degrees, 15degrees, or 20 degrees or less.

In one embodiment a snap ring segment 310 g can have a taper feature 322g, 332 g along one or more surfaces to help seat adjacent snap ringsegments 310 g with each other when in a straightened, rigid or anaxially compressed configuration. In various embodiments, a maximumrotational displacement angle 305 along a taper feature 322 g in acompressed configuration 306 can be no more than about zero degrees, 0.5degrees, 1 degree, 2 degrees, 3 degrees, or 5 degrees or less.

In one embodiment a snap ring segment 310 g can have one or more flatfeatures 321 g and one or more taper features 322 g along the surfacesdefining central lumen or channel 340 g that are configured to allowbending between adjacent segments of the segmented intramedullarystructure 300 in only a single plane when the adjacent segments are atleast partially distracted and/or bent with respect to each other. Invarious embodiments, a maximum rotational displacement angle 305 along ataper feature 322 g in a bent configuration 307 can be 1 degree, 3degrees, 5 degrees, 10 degrees, 20 degrees, 30 degrees, 45 degrees, or60 degrees or less.

In one embodiment corresponding taper features 322 g, 332 g enableeasier engagement of the adjacent snap ring segments 310 g when they arecompressed together. In one embodiment the male mating section 320 gincludes one or more taper features 322 g configured to interface withone or more taper features 332 g on the female mating section 330 g.

In various embodiments segments 310 can have various features along thechamber 340 and the outside surfaces. In various embodiments, surfacesmay have chamfers, radii, or other transition structures. As illustratedin one embodiment illustrated at FIG. 55B, starting at the proximal end336 of the chamber 340 g, the snap ring segment 310 g female matingsection 330 g has a proximal chamber edge 360 and a proximal chambersurface 362. In some embodiments, the proximal chamber surfaces 362 canbe substantially linear and inclined from the longitudinal axis toprovide a frusto-conical chamber increasing in inside diameter in theproximal direction.

In one embodiment a first articulation chamber 333 g has proximaltransverse stop or surface 364, a first articulation wall surface 366,and a distal surface 368. An optional second articulation chamber 334 ghas proximal stop or surface 372, a second articulation wall surface374, and a distal stop or surface 376. The stop surfaces on articulationchambers 333 g and 334 g may be in the form of an annular shelf ortransverse surface residing on a plane transverse to the longitudinalaxis.

The chamber 340 g surface continues to extend from the female matingsection 330 g into the male mating section 320 g with lumen surface 378,which extends toward the distal end 326 of the snap ring segment 310 g.In one embodiment the exterior of the male mating section 320 g has adistal end surface 380, a distal lip wall 382, a distal snap ringarticulation surface 384, a snap ring articulation wall surface 386, aproximal snap ring articulation surface 388, step surface 324 g, aproximal step surface edge 392, a distal male exterior surface 390 and adistal male exterior surface edge 394. In various embodiments, thedistal male exterior surfaces 390 can be a linear or flat feature 321 gparallel to the longitudinal axis or a taper feature 322 g, inclinedwith respect to the longitudinal axis and decreasing in a transversedimension in the distal direction.

With reference to FIGS. 56A-E in one embodiment, a pair of snap ringsegments 310 g in a bent configuration 307 are rotated with respect toeach other in the side view in FIGS. 56A-56B but remain substantiallyaxially aligned in the front view in FIGS. 56C-56D. With reference toFIGS. 57A-E in one embodiment, a pair of snap ring segments 310 g are inaxial alignment with respect to each other in a compressed configuration306. In one embodiment the snap ring 323 g allows the snap ring segments310 g to be assembled together easily and retains the snap ring segments310 g together so they do not fall apart when the assembly isdistracted.

FIGS. 58A-58D illustrate embodiments of segments 310 in variousconfigurations. FIG. 58A illustrates an embodiment of a pair of segments310 that are detached. FIG. 58B illustrates an embodiment of a pair ofsegments 310 that are in an assembled but distracted configuration 308.FIG. 58C illustrates an embodiment of a pair of segments 310 that are ina bent configuration 307. FIG. 58B illustrates an embodiment of a pairof segments 310 that are in a compressed configuration 306. In oneembodiment a snap ring 323 g is disposed on a snap ring articulationwall surface 386 of a male mating section 320 g of a first snap ringsegment 310 g. The first snap ring segment 310 g can be pushed oradvanced in to a second snap ring segment 310 g, deflecting the snapring 323 g into a radially reduced configuration that snaps back into aradially expanded configuration inside a first articulation chamber 333g or a second articulation chamber 334 g. In one embodiment, the snapring 323 g permanently connects the adjacent segments 310 g together sothat the adjacent segments 310 g do not detach from each other.

In one embodiment the snap ring 323 g (see FIGS. 56A-58D) provides forease of assembly of adjacent snap ring segments 310 g. The snap ring 323g can also lock to retain adjacent snap ring segments 310 g together sothey do not fall apart when the segmented intramedullary structure 300is distracted, moved or subjected to tensile forces. In one embodiment asnap ring segment 310 g can be distracted or pulled apart axially toallow two or more snap ring segments 310 g to bend in one plane. In oneembodiment a snap ring segment 310 g can be distracted or pulled apartaxially to allow two or more snap ring segments 310 g to bend about oneaxis.

In one embodiment the snap ring 323 g is an annular or arcuate length ofa resilient material such as stainless steel, Nitinol, Titanium, aTitanium alloy, or other material with an open section configured toallow a certain range of bending or flexing or temporary deformation ofthe snap ring 323 g in order to snap the snap ring 323 g in to alocation. In one embodiment snap ring 323 g is a C-shaped ring andserves to create an interference fit between adjacent snap ring segments310 g to permanently join them together. In various embodiments snaprings 323 g are sized proportionately depending on the size of the snapring segments 310 g being joined. In one embodiment the snap ring 323 ghas a feature for assisting in the removal of the snap ring 323 g fromthe location. In one embodiment a snap ring 323 g is disposed to berotatable, and axially slideable along the snap ring articulation wallsurface 386 at least between the distal snap ring articulation surface384 and the proximal snap ring articulation surface 388. In oneembodiment a snap ring 323 g is configured to stop or limit motionagainst one or more surfaces in one or more articulation chambers 333 g,334 g. In one embodiment a snap ring 323 g can be configured to stopagainst a surface in order to connect adjacent snap ring segments 310 gwhile limiting the relative motion between the adjacent snap ringsegments 310 g. For example, in various embodiments a snap ring 323 g isconfigured to stop against a proximal surface 364 of a firstarticulation chamber 333 g and a distal snap ring surface 384 to preventadjacent snap ring segments 323 g from detaching from each other asillustrated in FIGS. 56B, 56D and 58B.

In one embodiment a snap ring 323 g is configured to stop against adistal surface 368 of a first articulation chamber 333 g and a proximalsnap ring articulation surface 388 to limit the compression of adjacentsnap ring segments 323 g. In one embodiment a distal end surface 380 ofa male mating section 320 g contacts a distal surface 376 of a secondarticulation chamber 334 g to limit the compression of adjacent snapring segments 323 g.

In one embodiment the step surface 324 g is slideably and/orrotationally moveable with respect to the distal chamber surface 362 andthe distal chamber edge 360. For example, in an embodiment with twoadjacent segments 310, there is a proximal segment and a distal segment.In one embodiment of a compressed configuration, the distal maleexterior surface edge 394 of the proximal segment is close to or incomplementary contact with distal chamber edge 360 of the distalsegment. In articulating the proximal segment and the distal segmentbetween the compressed and the bent configurations (see FIGS. 57B and56B, respectively), the distal lip wall 382 of the proximal segment'smale mating section 320 g moves in a proximal direction through thesecond articulation chamber 334 g with respect to the distal segment.The distal lip wall 382 of the proximal segment's male mating section320 g can move in a proximal direction through the second articulationchamber 334 g and into the first articulation chamber 333 g. As theproximal segment moves away from the distal segment, the taperedfeatures 322 g open up and get wider to allow the proximal segment torotate or bend substantially within a plane parallel to flat features321 g in the male and female mating sections 320 g and 330 g. In oneembodiment of the bent configuration 306, the proximal step surface edge392 of the proximal segment is close to or in contact with distalchamber edge 360 of the distal segment.

In various embodiments, interaction between features on the interiorand/or exterior surfaces of adjacent segments 310 can be configured toadjust or determine the axial distraction range of motion and/orrotational bending range of motion of the segments 310 with respect toeach other. For example, in various non-limiting embodiments the axialdisplacement length 304 and/or the rotational displacement angle 305 canbe altered by changing tapers, radii, dimensions of parts, or features,such as changing the snap ring 323 g thickness, changing the distancebetween the proximal step surface edge 392 and the distal male exteriorsurface edge 394 on a snap ring segment 310 g, changing the distancebetween the proximal snap ring surface 388 and the distal snap ringsurface 384 on a snap ring segment 310 g, or changing the firstarticulation chamber 333 g height (distance from proximal surface 364and distal surface 368).

Referring to FIGS. 58B-58D, operation of the segmented intramedullarystructure 300 implant is best illustrated. In FIG. 58B, a first,proximal segment 310 g is interlocked with a second, distal segment 310g, and placed under axial traction. Proximal movement of the proximalsegment 310 g causes surface 384 to advance snap ring 323 g to theproximal limit of travel within first articulation chamber 333 g. Atthat point, further relative axial distraction of the two segments islimited by stop surface 364. In this distracted configuration 308, thetwo segments 310 may be inclined with respect to each other, enablingthe assembled implant to be bent into a curved configuration 307, suchas for implantation around a curve, and to facilitate removal as will bediscussed below.

In one embodiment during implantation, the implant needs to be able tobe placed under axial compression as it is advanced around a curve. Thisis permitted as seen in FIG. 58C, with the distally facing proximal stepsurface edge 392 engaging proximally facing proximal chamber edge 360 topermit axial compression without axial shortening of the implant, andsimultaneously permit axial compression while permitting the implant toretain a curve.

Once the implant has reached the approximately linear configuration ofthe intramedullary canal, distally facing proximal step surface edge 392disengages laterally from proximally facing proximal chamber edge 360 asthe angle between the two segments 310 decreases. This enables theproximal segment 310 g to axially advance further into distal segment310 g under further axial compression such as by pushing distally on adeployment tool, as illustrated in FIG. 58D. As seen therein, thecomplementary internal surfaces of the two segments 310 urge the axiallycompressed construct into a linear or substantially linear predeterminedconfiguration.

Thus, the implant has a first length, when under axial tension asillustrated in FIG. 58B. The implant can be shortened to a second lengthupon application of an axially compressive force, while the implant isin a nonlinear configuration as illustrated in FIG. 58C. The implant canbe further axially shortened to a third length by applying an axiallycompressive force while the implant is in a substantially linearconfiguration as seen in FIG. 58D. Preferably, the implant is thereafterlocked in the axially compressed and linear configuration of FIG. 58Dsuch as by applying axial tension on a tightening elongate member 350 asis discussed elsewhere herein.

When removal is desired, proximal traction on a proximal segment 310 maybe applied as will be discussed in additional detail below. Once theproximal segment 310 has broken free of any bony ingrowth that may haveoccurred, it will advance proximally to the proximal limit of travel asillustrated in FIG. 58B. This enables further proximal traction on theproximal segment 310 to be transferred on the next segment 310 in thedistal direction along the length of the implant 300. In this manner, aproximal, removal force can be transmitted directly from segment 310 tosegment 310 along the length of the implant 300, in addition to or inplace of reliance on the tensioning elongate member 350 extendingthrough central lumen or channel 340 g.

In one embodiment a segmented intramedullary structure 300 comprises asegment construct 303. The segment construct 303 comprises two or moresegments 310 including a distal end segment 400 and a proximal endsegment 500. In various embodiments, segments 310 can also comprise oneor more transition segments 314 and/or uniform segments 316 disposedbetween the distal end segment 400 and the proximal end segment 500.

In one embodiment transition segment 314 has a varying outer nominaldiameter or width dimension, and is configured to provide a transitionbetween segments 310 with different outer nominal diameter or widthdimensions. A plurality of transition segments 314 may be used totransition across nominal dimensions in incremental transition steps.For example, in the illustrated embodiment of FIGS. 56A-H, twotransition segments 314 are used to transition from a nominal width ordiameter dimension from the proximal end segment 500 to a uniformsegment 316. In various embodiments, different combinations oftransition segments 314 can be used to transition between a plurality ofnominal segment 310 dimensions. In one embodiment, the nominal dimensionchanges can be gradual, such as with a smooth taper. In one embodimentone or more transition segments 314 taper distally and serve togradually reduce the outer diameter of the segment construct 303. Forexample, in one embodiment, three transition segments 314 can be used totransition the body of the segment construct 303 down from an 11 mmdiameter of one embodiment of a proximal end segment 500 to oneembodiment of a uniform segment 316 nominal diameter of 8.0 mm diameter.The transition segments 314 can include an 11 to 10 mm transitionsegment 314, a 10 to 9 mm, and a 9 to 8 mm transition segment 314.

In one embodiment uniform segment 316 has a uniform outer nominaldiameter or width dimension. In one embodiment a uniform segment 316 hasa fixed diameter. In one embodiment a uniform segment 316 is a straightsegment. In one embodiment a uniform segment 316 is a curved segment. Invarious embodiments distal end segment 400 and proximal end segment 500are configured with a male mating section 320 or a female mating section330 that corresponds to the mating structure of an adjacent segment 310.In various embodiments the proximal end segment 500 and/or the distalend segment 400 can have a transition in nominal outer dimension widthor diameter. In one embodiment the distal end segment 400 tapersdistally.

The segment construct 303 is configured to be changeable between arelatively flexible, bent configuration 307 for insertion or extractionthrough a hole in an intramedullary canal and a relatively rigid, orless flexible compressed configuration 306 to provide a relativelystable anchor or fixation feature for the treatment of bone. FIGS. 59A-Hillustrate various views of an embodiment of a segmented intramedullarystructure 300 in a compressed configuration 306. FIG. 59G is a schematicperspective partially exploded view of the segmented intramedullarystructure 300 with a elongate member 350 extending between a proximalend 301 and distal end 302 of the intramedullary structure 300 throughthe channels 340 of the segments 310.

FIG. 60 illustrates various embodiments of segmented intramedullarystructures 300 in various bent configurations 307 with various lengths,diameters, materials and distal end segments 400 with variousembodiments of distal fixation structures. Although certain embodimentsof proximal and distal fixation structures in proximal end segments 500and distal end segments 400 may show one fixation embodiment, any of thedisclosed fixation structures can be mixed or used in combination withother or the same type of fixation structures on the proximal, distal,and/or intermediate portion of any embodiment of segmentedintramedullary structures 300. FIGS. 61-63 illustrate variousembodiments of distal end segments 400 of segmented intramedullarystructures 300 with various embodiments of distal fixation structures.

FIG. 61 illustrates one embodiment of a cross-screw distal fixationstructure segment 410 of an intramedullary structure has one or morepre-formed or pre-drilled cross throughbores 112 for a surgeon to use insecuring the distal end in the bone by using one or more bone screws 113through the bone and into one or more cross-holes at various angles toanchor and secure the distal end of the implant in the bone. In variousembodiments, bone screw 113 is the same or similar to locking bolt 54and/or locking bolt 60. In one embodiment bone screw 113 is a lockingscrew. In one embodiment bone screw 113 is a self-tapping screw. In oneembodiment bone screw 113 uses an internal hex interface for driving thescrew. In various embodiments bone screw 113 can have a major diametersand lengths and screwing interfaces configured for a particularapplication. In various embodiments a bone screw 113 has a majordiameter of 4 mm, 5 mm, 6 mm, or other diameters. In various embodimentsa bone screw has a length in the range of approximately 16 to 120 mm. Inone embodiment at least one bone screw 113 is used in at least onethroughbore 112 at the distal end segment 400. In one embodiment atleast one bone screw 113 is used in at least one throughbore 112 at theproximal end segment 500. In various embodiments, one, two, three, fouror more through holes 112 are provided in any segment 310. In oneembodiment a throughbore 112 is a tunnel in a segment 310. In oneembodiment throughbore 112 may merge with another throughbore 112 toform a multi-conduit pathway. Different throughbores 112 may be used oroptionally provided for options in fixing the device to bone.

FIG. 62 illustrates one embodiment of a polymer distal fixation segment412 of an intramedullary structure 300 that includes a strong, solidpolymer tip. In one embodiment the polymer is implantable-gradepolyetheretherketone (PEEK), or other similar materials. One advantageof a polymer distal fixation structure segment 412 is that the surgeoncan pierce the polymer distal fixation segment 412 in any angle ordirection to provide cross-screw fixation between the bone and implant.In one embodiment one or more bone screws 113 are used to providestructure between one side of the cortical bone, through the polymerdistal fixation segment 412, and into the other side of the corticalbone. For example, see FIGS. 39B and 40B. In one embodiment the polymerdistal fixation segment 412 is fixed to the intramedullary structure 300with a pin 413. In one embodiment the polymer distal fixation segment412 has one or more markers placed in it for radiopaque monitoring ofthe fixation process. In one embodiment the marker 414 is near a distalend of the polymer distal fixation segment 412. In one embodiment themarker can be a ring or other structure or shape for visualization undermonitoring devices such as fluoroscopy.

With respect to FIG. 63, one embodiment of a radially-expandable distalfixation segment 415 of an intramedullary structure can be called“hinged fingers.” In one embodiment, radially-expandable distal fixationsegment 415 is the same or has similar features to an embodiment of theradially-expandable distal end segment 114 described above. In oneembodiment, a radially-expandable distal fixation segment 415 comprisestwo or more rigid members 416 (also called hinged fingers) that can openup like a flower when the ball (or actuator 417) at the end of theelongate member 350 is pulled up proximally through the intramedullarystructure. One embodiment includes three or more rigid members 416. Inone embodiment the rigid members 416 do not bend. One embodiment hasmetal rigid members 416. In one embodiment one or more hinged fingermembers 416 have a surface texture configured to improve fixation tobone. In one embodiment the surface texture is grooves. In oneembodiment, the ball 417 is attached to the distal end of the elongatemember 350. When the elongate member 350 is pulled proximally toward theproximal end 301 of the segmented intramedullary structure 300 the ballmoves proximally until the hinged fingers 416 seat on sufficientlystable bone in or around the intramedullary canal. In one embodiment theball 417 can move off the central longitudinal axis of theintramedullary device since the elongate member 350 is flexible,allowing the ball 417 to apply pressure to actuate the various hingedfingers 416 until a sufficient number of hinged fingers 416 is properlyanchored, irrespective of irregular bony geometry in the intramedullarycanal. This self-centering aspect of the ball 417 and elongate member350 is another advantage of the present embodiment.

In one embodiment distal end segment 400 has a proximal end 401 and adistal end 402. In one embodiment distal end segment 400 has a male orfemale end portion configured for attachment with an adjacent, proximalsegment 310. In one embodiment the proximal end 401 of the distal endsegment 400 has a female mating section 430 similar to any embodiment ofa female mating section 330 in a segment 310. In one embodiment distalend segment 400 has a channel 440 extending longitudinally therethrough.In one embodiment channel 440 is similar to channel 340 in a segment310. In one embodiment channel 440 is configured to align with and workin conjunction with channel 340 in one or more segments 310 and anelongate member 350. In one embodiment a distal end segment 400 isconfigured to distally anchor an elongate mechanism, such as atensioning rod 14, threaded rod, or elongate member 350.

In one embodiment elongate member 350 is flexible. In one embodimentelongate member 350 comprises a braided cable 352. In one embodimentelongate member 350 comprises a metal cable. In one embodiment elongatemember 350 comprises a braided Titanium cable. In one embodimentelongate member 350 serves as a post-reaming guide for placing thesegmented intramedullary structure 300 into an intramedullary canal 40of a bone 42. In one embodiment the elongate member 350 is insertedthrough an entry point in the cortical bone in to the intramedullarycanal 40 and distally past a fracture site 44 in a bone 42.

In one embodiment elongate member 350 comprises a ferrule 356 at thedistal end of the elongate member 350. In one embodiment ferrule 356 isattached to the distal end of the braided cable 352. In one embodimentferrule 356 is crimped to the distal end of the braided cable 352. Inone embodiment ferrule 356 is welded to the distal end of the braidedcable 352. In one embodiment ferrule 356 is crimped and welded to thedistal end of the braided cable 352. In one embodiment ferrule 356serves as a stop at the end of the elongate member 350. In oneembodiment ferrule 356 is a Titanium alloy.

In one embodiment elongate member 350 comprises a braided cable 352 atleast partially disposed within a lumen of a tube 354. See FIGS. 65 and65A. In one embodiment the tube 354 is flexible. In one embodiment thetube 354 is a Nitinol tube. In one embodiment the tube 354 has an outerdiameter of 0.085″, an inner diameter of 0.065″, and a wall thickness of0.010″. In one embodiment the tube 354 stiffens the elongate member 350to facilitate the insertion of the segmented intramedullary structure300 over the elongate member 350, across the fracture site 44. In oneembodiment the super elastic properties of Nitinol can prevent orminimize the permanent deformation of the elongate member 350 if bendingof the elongate member 350 at the fracture site 44 occurs. In oneembodiment the tube 354 runs from the distal end of the elongate member350 to just below the proximal end segment 500 when the segmentedintramedullary structure 300 is fully compressed.

In one embodiment the elongate member 350 is tensioned to compress theimplant segments 310 together to form a relatively rigid construct. Inone embodiment the proper placement of the segmented intramedullarystructure 300 can be confirmed with fluoroscopy prior to the tensioningof the elongate member 350. In one embodiment the elongate member 350 ismanually tensioned. In one embodiment the elongate member 350 ismanually tensioned by pulling proximally on the elongate member 350 withrespect to the segmented intramedullary structure 300. In one embodimentthe elongate member 350 is tensioned or further tensioned with a cabletensioner assembly 200. In one embodiment, when fully tensioned, theelongate member 350 is locked in place with a collet screw 280 in theproximal end segment 500. In one embodiment an end cap 290 is placed andthen the elongate member 350 is cut flush with the top of the end cap290. In one embodiment, when the elongate member 350 is fully tensionedand the segmented intramedullary structure 300 becomes rigid, the tube354 is enclosed by the segmented intramedullary structure 300 and is nolonger is loaded. In various embodiments, distal end segment 400 can beany of the embodiments of a distal end segment. In one embodimentillustrated at FIG. 64, the distal end segment 400 can be a cross-screwdistal fixation structure segment 410.

In one embodiment the proximal end segment 500 has a proximal end 501and a distal end 502 with a channel 540 extending between the proximalend 501 and distal end 502. FIGS. 66-68 illustrate one embodiment of aproximal end segment 500. In one embodiment the proximal end segment 500has a proximal section 510 near the proximal end 501. In one embodimentthe proximal end segment 500 has a distal section 520 near the distalend 502. In one embodiment the proximal end segment 500 has athroughbore section 530 between the proximal end 501 and distal end 502.In one embodiment distal section 520 has a male or female end portionconfigured for attachment with an adjacent, distal segment 310. In oneembodiment the distal end 502 of proximal end segment 500 has a distalsection 520 similar to any embodiment of a male mating section 320 in asegment 310. In various embodiments proximal end segment 500 is hassimilar features as proximal end segment 110 described above.

In one embodiment the proximal end segment 500 is slightly curved suchthat its proximal end 501 reaches cortical bone proximal to the fracturesite 44 while its distal end is in the intramedullary canal 40. In oneembodiment throughbore section 530 has four through-holes, orthroughbores 112, to allow for placement of one, two, three or four bonescrews 113 at the proximal end 301 of the segmented intramedullarystructure 300. In one embodiment, two of the throughbores 112 areoriented for bone screws 113 placed from the right, and two of thethroughbores 112 are oriented for bone screws 113 placed from the left.

In one embodiment a cable collet anchor 272 is permanently fixed withinthe proximal section 510. In embodiment cable collet anchor 272 ispermanently fixed within the proximal section 510 with a pin (notillustrated) in a pin hole 511, which can be welded in place afterinsertion. In embodiment cable collet anchor 272 is permanently fixedwithin the proximal section 510 by welding. In embodiment cable colletanchor 272 is permanently fixed within the proximal section 510 with aninterference fit between the two components. In embodiment cable colletanchor 272 is integral, or unitary, with the proximal section 510.

In one embodiment the cable collet anchor 272 is configured to interfacewith a cable tensioner assembly 200. In one embodiment interface 512provides a notch or other feature to facilitate the interfacing orconnection between the cable collet anchor 272 and the cable tensionerassembly 200. In one embodiment a cable tensioner assembly 200 is usedto tighten, or increase tension in a elongate member 350 in order tomake the segmented intramedullary structure 300 less flexible, such asduring device implantation. In one embodiment a cable tensioner assembly200 is used to loosen, or decrease tension in a elongate member 350 inorder to make the segmented intramedullary structure 300 more flexible,such as during device extraction.

In one embodiment the cable collet anchor 272 is threaded to mate withthe collet screw 280 with a channel 281 configured to grip elongatemember 350 with a plurality of flexible fingers 284. In one embodimentthe cable collet anchor 272 has one or more tapered walls 276 to forcethe plurality of flexible fingers 284 to close around the elongatemember 350 as the collet screw 280 is tightened by rotating it distally.In one embodiment the outer surface of the flexible fingers 284 aretapered distally. In one embodiment the outer surface of the flexiblefingers 284 are substantially cylindrical. In various embodiments thecollet screw 280 can have three, four, five or more flexible fingers284. The illustrated collet screw 280 at FIG. 69 has three flexiblefingers 284. In one embodiment a driver shaft 252 of a collet driver 250can used to tighten or loosen the cable collet screw 280 by interfacingwith a cable collet screw interface 283. In one embodiment cable colletscrew interface 283 has a shaped inner wall 286. In various embodimentsshaped inner wall 286 is a hex shape, or other keyed type shape. In oneembodiment cable collet screw interface 283 has a shaped outer wall. Inone embodiment the shaped outer wall is a hexagonal shape, such as witha nut.

In one embodiment an end cap 290 serves to prevent bone formation overthe device entry point. In various embodiments the end cap 290 can beconfigured to attach at the distal end 501 of the proximal end segment500. In various embodiments, the end cap 290 can be offered in variouslengths to allow the surgeon to position the end of the end cap 290 sothat it is just below the cortical margin. In various embodiments, theend cap 290 can have an additional length of +0 mm, +5 mm, +10 mm, +15mm, or +20 mm. In one embodiment end cap 290 has external threads thatmate with internal threads on the proximal end segment 500. In oneembodiment end cap 290 has internal threads that mate with externalthreads on the proximal end segment 500. In one embodiment end cap 290has a reversible snap fit connection with the proximal end segment 500.In one embodiment, once the end cap 290 is in place, the elongate member350 is cut flush with the proximal surface of the end cap 290.

Procedures for Manufacturing, Assembling or Installing a SegmentedIntramedullary Structure

In various embodiments, steps for installing a segmented intramedullarystructure may include optional steps, and steps that can be taken in orout of sequence. Different combinations of steps may be used dependingon the segmented intramedullary structure used, patient anatomy, thetreatment being provided, and/or medical practitioner preference. Asnoted above, FIGS. 14-22 schematically illustrate various embodiments ofprocedures for installing an embodiment of a segmented intramedullarynail into the intramedullary canal of a long bone. The followingembodiments of procedures can be used alone, in conjunction with, or incombination with the embodiments of the procedure described with respectto FIGS. 14-22 and described elsewhere herein. FIGS. 70-78 schematicallyillustrate various embodiments of procedures for installing anembodiment of a segmented intramedullary nail into the intramedullarycanal of a long bone.

In one embodiment a technique for implanting a segmented intramedullarystructure 300 can include any of the following general steps, such asreaming a canal in tissue to a diameter larger than the diameter of theselected segmented intramedullary structure 300, inserting a elongatemember 350 into the prepared canal, placing the selected segmentedintramedullary structure 300 over the elongate member 350, pulling onthe elongate member 350 to compress the segments 310 together, placingproximal and distal end locking screws 113, tensioning the elongatemember 350 with a cable tensioner assembly 200, locking the elongatemember 350 by tightening a cable collet screw 280 within the proximalend segment 500, threading an end cap 290 onto the proximal end of thesegmented intramedullary structure 300, or cutting the elongate member350 flush with the end cap 290 with a cable cutter instrument. In oneembodiment the technique for implanting a segmented intramedullarystructure involves reaming a canal in tissue to a diameter at least 1.0mm larger than the diameter of the selected segmented intramedullarystructure 300. In various embodiments of techniques for implanting asegmented intramedullary structure 300, various instruments can be used.Some non-limiting examples of optional instruments that can be usedinclude a guide wire, a ball-tip guide wire, a Kelly clamp, an exchangetube, a drill bit, a cable tensioner, a reamer, a flexible reamer set, atissue protector, a guidewire T-handle, an obturator, an implant lengthgauge, a proximal screw guide, a drill sleeve, a broach trial, a curvedbroach trial, a screw driver, a cannulated screw driver, a slap hammer,a back slapper, and a cable cutter.

In one embodiment, pre-operative planning includes measuringintramedullary canal 40 diameter and/or length in a bone 42. In oneembodiment a radiographic canal ruler can be used to measureintramedullary canal 40 diameter and/or length in a bone 42.

FIG. 70 illustrates one embodiment of an approach to an access site forthe implantation or removal of a segmented intramedullary structure 300.In the illustrated embodiment, the bone 42 is a humerus, but theapproach can be with any long bone and can occur at a distal or proximalend of the bone 42. In one embodiment, a patient is placed in a supineand in a semi-recumbent position (e.g., traditional “beach chair”position or tilted with the thorax “bumped” 30-40 degrees). A surgeoncan split the deltoid fibers longitudinally, taking care to avoid theaxillary nerve. In one embodiment, an access hole 46 is created at theaccess site. The surgeon can create an entry hole or access hole 46 justdistal to the insertion of the supraspinatus, below the greatertuberosity.

In one embodiment illustrated at FIG. 71, the surgeon can insert the tipof a broach 604 into the bone 42 at an approximately 45 degree angle tothe bone surface, at least 1 cm distal to the rotator cuff insertion. Inone embodiment the geometry of the cutting surfaces of the broach 604matches the proximal geometry of the segmented intramedullary structure300 to ensure properly sized proximal opening in the bone. In oneembodiment, an 11 mm diameter access hole 46 is used. Optionally, aguide wire and/or cone reamer can be used to open the access hole 46prior to insertion of the broach 604. The surgeon advances the broach604 into the medullary canal 40.

In one embodiment illustrated at FIG. 72, the surgeon can advance aguide wire 606 into the intramedullary canal 40, manually reduce thefracture 44, then advance the guide wire tip past the fracture site 44.In one embodiment the guide wire 606 has a 2 mm outer diameter. In oneembodiment the guide wire 606 includes a ball tip at its distal end. Inone embodiment the surgeon can confirm the position of the guide wire606 using fluoroscopy as needed. In one embodiment the surgeon centersthe ball-tip of the guide wire 606 at the distal end of theintramedullary canal 40.

In one embodiment illustrated at FIG. 73, the surgeon can measure theproper implant length. While maintaining fracture reduction with thedistal ball tip of the guide wire 606 in proper position, the surgeoncan place a Kelly clamp at a point as close as possible to the corticalentry point near access hole 46. The surgeon can proximally withdraw theguide wire 606 approximately 1 cm from the bone 42, and estimate thesegmented intramedullary structure 300 length by measuring the exposedguide wire 606 (indicated by the arrow with reference number 608) usingthe a device length gauge. The surgeon can record the length or selectan appropriate segmented intramedullary structure 300 and insert theguide wire 606 back into the intramedullary canal 40 and remove theKelly clamp.

In one embodiment illustrated at FIG. 74, the surgeon can ream theintramedullary canal 40. In various embodiments, one or more reamers 608can be used. In one embodiment, beginning with a small diameter flexiblereamer 608, such as in one example, a 6 mm flexible reamer 608, thesurgeon can ream the medullary canal by placing the reamer 608 over theguide wire 606 and advancing it into the canal while maintainingfracture reduction. In one embodiment no guide wire 606 is required. Inone embodiment the surgeon can use a tissue protector to prevent softtissue damage while reaming. In one embodiment the surgeon can graduallyincrease reamers 608 diameters (for example, the reamers 608 canincrease in diameter by 0.5 mm increments) until “chatter” is heard forthe reamer 608, indicating the proper implant diameter. In oneembodiment this diameter should correspond to preoperative estimatesusing radiographs or a radiographic canal ruler. Based on pre-opplanning, the final reamer 608 diameter should be at least 1.0 mm largerthan the nominal or central diameter of the chosen segmentedintramedullary structure 300 to minimize the potential for fracture sitedistraction. In one embodiment the surgeon can place an obturator overthe end of the guide wire 606 to hold it in position. The surgeon canremove the last reamer 608 by sliding it along the guide wire 606. Oncethe reamer 608 is out of the bone 42, the surgeon can remove theobturator and reamer 608.

In one embodiment illustrated at FIG. 75, the surgeon can select thediameter and length of the segmented intramedullary structure 300 basedon the last reamer 608 diameter combined with the previously measuredcanal length. The surgeon can insert an exchange tube 610 over the guidewire 606, remove the guide wire 606 and insert the elongate member 350.The surgeon can confirm the elongate member 350 position underfluoroscopy. The surgeon can remove the exchange tube 610, being carefulto maintain the position of the elongate member 350.

In one embodiment illustrated at FIG. 76, one embodiment of a segmentedintramedullary structure 300 being inserted in a bent configuration into a sectional view of a bone 42 according to an embodiment of thepresent invention. FIG. 76 illustrates one embodiment of an additionaloptional step in the method of inserting a segmented intramedullarystructure 300 in a bent configuration in to an intramedullary canal 40of a long bone 42 with an inserter guide 612. In one embodiment, aninserter guide 612 is a flexible, low friction strip with a widthapproximately equal to the width or diameter of the segmentedintramedullary structure 300. The inserter guide 612 is inserted intothe access hole 46 in the long bone 42 leading into the intramedullarycanal 40.

In one embodiment illustrated at FIG. 77, the surgeon can insert asegmented intramedullary structure 300 into the bone 42. In oneembodiment the surgeon can attach a proximal fixation screwguide-interface 104, or proximal drill guide, onto the proximal end 301of the segmented intramedullary structure 300. In one embodiment thesurgeon can use a locking bolt with a quick connect mechanism. Thesurgeon can advance the segmented intramedullary structure 300 over theproximal end of the elongate member 350. With the segmentedintramedullary structure 300 in a flexed or bent configuration, thesurgeon can advance the segmented intramedullary structure 300 over theelongate member 350 into the medullary canal 40. The surgeon can cakecare to maintain the elongate member 350 position across the fracture 44while advancing the segmented intramedullary structure 300 over theelongate member 350. In one embodiment the surgeon can optionallyslightly rotate the proximal end 301 of the segmented intramedullarystructure 300 to assist with insertion. The surgeon can sink the mostproximal portion of the segmented intramedullary structure 300 at least5 mm below the bone cortex and confirm position with fluoroscopy. In oneembodiment the surgeon can apply preliminary tension to the elongatemember 350 by manually pulling on the proximal end of the exposedelongate member 350 to compress the segments 310 of the segmentedintramedullary structure 300 together. The surgeon can take caution notto bend or kink the elongate member 350 near the segmentedintramedullary structure 300.

In one embodiment illustrated at FIG. 78, the surgeon can fixate thesegmented intramedullary structure 300 with respect to the bone 42. Inone embodiment the surgeon can fixate the segmented intramedullarystructure 300 with respect to the bone 42 with proximal and distal bonescrews 113. In other embodiments, other fixation techniques can be used.The surgeon can confirm that the proximal portion of the IFS is flush orslightly below the cortex of the bone 42. The surgeon can create anincision in line with the most proximal screw throughbore 112. In oneembodiment two proximal throughbores 112 are configured for left-sidedor right-sided access, and are close enough in proximity to have bothbone screws 113 inserted through a single incision, approximately 5 mmlong. The surgeon can bluntly dissect the incision to the cortex, takingcare to avoid the axillary nerve and any of its arborized branches. Thesurgeon can spread the tissues and insert a proximal fixation screwguide-interface 104 until it contacts the bone 42. In one embodimentself-tapping bone screws 113 can be inserted with the proximal fixationscrew guide-interface 104 through the bone 42 and into the throughbores112 of the segmented intramedullary structure 300. In one embodiment theproximal fixation screw guide-interface 104 includes a 3.2 mm proximaldrill sleeve. The surgeon can maintain the position of the proximalfixation screw guide-interface 104 against the bone 42 and use a drillbit to drill through the near and far cortices of the bone 42. In oneembodiment the drill bit is a 3.2 mm calibrated drill bit. In surgeoncan optionally stop drilling immediately after penetrating the farcortex of the bone 42. The surgeon can measure the necessary length forthe bone screw 113 using the drill bit, a calibrated drill bit, or acalibrated measuring device. In various embodiments, the bone screw 113can include diameters and length appropriate for the application. Insome embodiments, the bone screw 113 has a diameter of 4.0 mm, 5.0 mm,or 6.0 mm, and a length in a range from about 16 mm to about 120 mm. Thesurgeon can select a bone screw 113 and insert it through the selectedthroughbore 112 of the segmented intramedullary structure 300 with ascrew driver. In one embodiment the screw driver is a hex driver. Thesurgeon can repeat the procedure for the more distally-positionedproximal bone screw 113. In one embodiment, the more distally-positionedproximal bone screw 113 can be inserted before the moreproximally-positioned proximal bone screw 113. The surgeon can reconfirmfracture 44 reduction with a visualization technique, such asfluoroscopy. The surgeon can ensure the segmented intramedullarystructure 300 segments 310 are mostly compressed by manually tensioningthe elongate member 350 as necessary by pulling on the proximal end ofthe elongate member 350. In one embodiment the surgeon avoids lockingthe segmented intramedullary structure 300 with distraction between thebone segments at the fracture 44. In one embodiment, the surgeon canplace the patient's elbow on a mayo stand to support it to reducedistraction between bone segments at the fracture 44. The surgeon canutilize an AP view of the distal humerus and make a longitudinalincision over the segmented intramedullary structure 300 distalthroughbores 112. The surgeon can identify the biceps fascia, split thefascia and deliver the drill tip to the bone 42. The surgeon can takecaution to ensure drill tip placement so as to avoid inadvertentmedialization of the drill tip. In one embodiment the surgeon can drillthe holes in the bone for the distal bone screws 113. In one embodimentthe surgeon can use self-tapping distal bone screws 113. In oneembodiment the surgeon can insert the bone screws 113 using a freehandtechnique.

In one embodiment illustrated at FIG. 78, the surgeon can tension theelongate member 350 in the segmented intramedullary structure 300, whichcompresses the segments 310 with a cable tensioner assembly 200. In oneembodiment the surgeon can ensure that the cable tensioner assembly 200is ready to accept the elongate member 350 by loosening the tensioningthreaded knob 240 until it stops. In one embodiment the loosening of thetensioning knob is counter-clockwise. In another embodiment theloosening of the tensioning knob is clockwise. The surgeon can insertthe cable collet screw 280 into the distal end of the cable tensionerassembly 200 and press the cable collet screw 280 to firmly seat it onthe cable tensioner assembly 200. The surgeon can slide the cabletensioner assembly 200 over the exposed elongate member 350 and attachcable tensioner assembly 200 to the proximal fixation screwguide-interface 104. In one embodiment the proximal fixation screwguide-interface 104 is already in place. In one embodiment the proximalfixation screw guide-interface 104 and cable tensioner assembly 200 canattach using a quick connect mechanism.

In one embodiment segmented intramedullary structure 300 elongate member350 tensioning occurs in two steps: 1) tensioning of the elongate member350, and 2) locking of the elongate member 350 with the cable colletscrew 280. In one embodiment, when the cable tensioner assembly 200 issecurely connected to the proximal fixation screw guide-interface104—segmented intramedullary structure 300 construct. The surgeon cantighten the collet driver 250 knob by turning it 1-2 turns clockwise topartially advance the locking collet threads 282 of the cable colletscrew 280 into the proximal end 301 of the segmented intramedullarystructure 300. This step ensures proper threading of the cable colletscrew 280 into the cable collet anchor 272 of the segmentedintramedullary structure 300. The cable collet screw 280 should not befully tightened yet. The surgeon can confirm the segmentedintramedullary structure 300 position and fracture 44 reduction usingfluoroscopy. The surgeon can apply tension to the elongate member 350 byrotating the tensioning threaded knob 240 clockwise until the tensionindicator markings 247 reaches the 100 pound mark. In one embodiment thesurgeon does not exceed 125 pounds of tension. Tensioning elongatemember 350 should apply compression across the fracture site 44, suchthat the gap is reduced or eliminated between the fracture 44 fragments.Tensioning elongate member 350 should also reduce or eliminate gapsbetween the segments 310. The surgeon can confirm the position of thesegmented intramedullary structure 300 and confirm fracture 44 reductionusing a C-arm or fluoroscopy. The surgeon can locks the tensionedelongate member 350 within the segmented intramedullary structure 300 bytightening the cable collet screw 280 by rotating the collet driver 250,which rotates the driver shaft 252, clockwise to fully “seat” the cablecollet screw 280.

In one embodiment, after the cable collet screw 280 has been secured,the surgeon can release the cable tensioner assembly 200 by looseningthe tensioning threaded knob 240 until it stops. This will release thecable tensioner assembly 200 from the elongate member 350. The surgeoncan release the quick connect outer ring to remove the cable tensionerassembly 200 and proximal fixation screw guide-interface 104 from thesegmented intramedullary structure 300.

In one embodiment the surgeon can select an appropriate end cap 290 andslide it distally over the exposed elongate member 350. The surgeon canthread the end cap 290 into place using an end cap driver. The surgeoncan confirm the position of the segmented intramedullary structure 300using fluoroscopy. The surgeon can use cable cutters to cut the elongatemember 350 as close to the proximal end 301 of the segmentedintramedullary structure 300 as possible. In one embodiment the surgeoncan cut the elongate member 350 as close to the proximal end of the endcap 290 as possible. The surgeon can close the wound in layers.

In various embodiments, different combinations of segments 310 can beassembled or manufactured into a custom segmented intramedullarystructure 300 based on specific parameters of the bone in which thesegmented intramedullary structure 300 will be implanted. In variousembodiments, different combinations of segments 310 can be used orcombined in a modular fashion to assemble custom made segmentedintramedullary structures 300 based on the bone and application for thestructure. In various embodiments the overall configuration or shape ofthe segmented intramedullary structure 300 may be straight,substantially straight, or curved along any one segment 310 or any setsof segments 310 depending on the selection of parts from an array ofparts with various shapes, sizes and features. Each segment 310 can besubstantially straight or curved, and any set of segments 310 can haveinterfaces providing for angles between adjacent segments 310. Invarious embodiments, segments 310 can also comprise one or moretransition segments 314 and/or uniform segments 316 disposed between thedistal end segment 400 and the proximal end segment 500. Segments 310can be selected based on features the segments 310 have for use based onan evaluation of parameters of the bone for implantation. Parameters, asdiscussed herein, can include bone or intramedullary canal diameter,length, width, height, curvature (if any), deviation from linear,fracture geometry, bone geometry, tissue geometry, anatomical featuressuch as abnormalities or other features, to name a few. In variousembodiments, different combinations of embodiments of segments 314and/or uniform segments 316 can be disposed between differentembodiments of a distal end segment 400 and different embodiments of aproximal end segment 500. Referring to one embodiment illustrated inFIG. 79, different non-limiting embodiments of a proximal end segment500 a, 500 b, and 500 c, with different features, such as variouscurvatures (if any), lengths, orientations, features of throughbores112, locking mechanisms, and more can be selected depending onparameters of the bone or patient in which the structure is to beimplanted. Similarly, different non-limiting embodiments of a distal endsegment 400 d, 400 e, 400 f can be selected. Likewise, any combinationof uniform segments 316 can be used, with different sizes arranged withcomplementary interfaces. In one optional embodiment various uniformsegments 316 may be used with complementary interfaces but havedifferent outer body parameters, such as diameter, texture or otheralignment or bone engagement or bone ingrowth enhancing structure.Likewise, any combination of transition segments 314 can be used, withdifferent sizes arranged with complementary interfaces. Variouscombinations of transition segments 314 may be used for a continuoustransition along a number of transition segments 314, or can vary intaper with increases in diameter or width as desired depending on thesequence of segment 310 assembly.

In one method of assembly, manufacture, or construction of the segmentedintramedullary structure 300, a surgeon could assemble a modular orcustom segmented intramedullary structure 300 while in the operatingroom. In one embodiment an evaluation of bone parameters using anyimaging or assessment technique can be used, then a series of segments310 could be assembled using a selected or suitable series and number ofsegments 310 based on the bone evaluation. In one embodiment a segment310 may be selected based on the best fitting curvature, orientation,and/or throughbores 112 for a surgical approach to the bone. Differentsegments 310 can be selected for accommodating for a fracture, increasedstability, screw placement, and other aspects relating to features andparameters of the device with the bone.

Typically, at least a proximal segment, a distal segment and anintermediate segment will be assembled to form a final construct.Depending upon the desired length of the assembled implant, at leasttwo, or three or five or more intermediate segments may be used. Each ofthe intermediate segments is provided with a proximal interface, forengaging a proximally adjacent segment, and a distal interface forengaging a distally adjacent segment. The proximal and or distalinterfaces may be provided with a retention lock such as a snap ring ashas been described elsewhere herein or other complementary retentionstructure. The retention lock permits the physician to connect twoadjacent segments together while assembling the implant, and also topreserve the implant removal feature discussed below.

In the modular, customizable device, the distal end segment may beprovided with a proximally extending tightening element such as a pullor push element, rotatable shaft or other structure for locking thefinished implant in its implanted configuration. Each of theintermediate segments is provided with an axially extending lumen, forreceiving the tightening element therethrough. During assembly, thephysician feeds the axially extending tightening element from the distalmost segment through each successive intermediate segment until thedesired length is reached. The proximal segment is provided with a lock,for locking the tightening element. The tightening element may beprovided with an initial length which exceeds the length of theassembled implant. The proximal excess of the tightening element can becut off or otherwise detached and discarded to conform to the length ofthe implant. Alternatively, it may be left subcutaneously so that it canbe retrieved and used as a guide to the implant for future revisionsurgery. Alternatively, the tightening element may be provided in amodular configuration, with a portion of the tightening element carriedby each segment, so that it is effectively assembled as each successivesegment is connected to the implant.

Procedures for Extracting or Removing a Segmented IntramedullaryStructure

In one embodiment an implanted segmented intramedullary structure 300can be removed from the patient. In one embodiment an implantedsegmented intramedullary structure 300 can be removed from the patientby reversing some of the steps used in implantation. In one embodimentthe surgeon can access the access hole 46 in the bone with an incisionand moving tissue out of the way. Visualization techniques, such asfluoroscopy, or manual palpation of the tissue can be used to locatebone screw 113 extraction sites. Use of minimally invasive,percutaneous, or open surgical techniques can be used to access theaccess site and screw sites in the patient. In one embodiment the endcap 290 is removed. In one embodiment the bone screws 113 are removed.In one embodiment the cable collet screw 280 is loosened. In oneembodiment the cable collet screw 280 is loosened with a collet screwremoval tool. In one embodiment the cable collet screw 280 is loosenedwith a cable tensioner assembly 200 operated in a manner to reducetension in the elongate member 350. In one embodiment, the proximal endof the elongate member 350 is grasped with a tool for extracting theelongate member 350. In one embodiment extraction of elongate member 350pulls the distal end segment 400 of the segmented intramedullarystructure 300 in a proximal direction toward the access hole 46. In oneembodiment the cable collet screw 280 is loosened, moved proximallyalong elongate member 350, and tightened back on the elongate member 350to grasp the elongate member 350 at a more proximal location. In oneembodiment a loosened elongate member 350 releases segments 310 in thesegmented intramedullary structure 300 from the compressedconfiguration, allowing the segments 310 to distract or move withrespect to each other. In one embodiment the tension in elongate member350 is reduced enough to allow adjacent segments 310 in the segmentedintramedullary structure 300 to move into a bent configuration 307sufficient for extraction of at least one segment 310 though the accesshole 46. In one embodiment segments 310 are removed from bone 42sequentially. In one embodiment, it is possible that the segmentedintramedullary structure 300 is attached to patient tissue or bone, orthat some bone cement or adhesives were used around the implanteddevice, or other additional anchoring mechanisms. In one embodiment theproximal end 301 of the segmented intramedullary structure 300 may betapped or vibrated with a hammer or device configured to shake orvibrate the segmented intramedullary structure 300 at a frequency, suchas a resonant frequency, to assist in the removal of the segmentedintramedullary structure 300 from the bone 42. In one embodimentextraction of a segmented intramedullary structure 300 includesproviding sufficient force to break one segment 310 free from thesurrounding bone at a time. For example, the force required to shear thebone ingrowth into one segment, such as the most proximal segment 310,is less than the force required to shear the bony ingrowth throughoutthe length of the entire segmented intramedullary structure 300 at once.For example, resistance to removal may correlate to surface area of theimplant being removed. If one segment is broken free at a time, theresistance to overcome removal would be proportionate to the surfacearea of that one segment instead of the entire implant. In oneembodiment the shear force to free one segment 310 is less than theshear force to free multiple segments 310 at the same time. In oneembodiment extraction of a segmented intramedullary structure 300includes attaching a removal device to the most proximal segment 310 andpulling the most proximal segment 310 proximally. In one embodiment theremoval device is a slap hammer, and the slap hammer is attached to themost proximal segment 310 and actuated with sufficient force to free themost proximal segment 310 from the bone 42. In various embodiments thesnap ring or other locking structure permits distraction betweenadjacent segments of at least about 0.5 mm, generally at least about 1mm or 2 mm but often no more than about 5 mm or 10 mm. As a result, aloosened segment 310 may be proximally retracted to the limit of itstravel. Further proximal force applied to the segment 310 will betransferred by the locking structure to the next adjacent distal segmentso that it may be broken free from surrounding bone 42. The process canbe repeated to remove all segments 310 from the bone 42.

Thus, an improved intramedullary structure has been provided asdescribed above. While the structure has been described in terms ofcertain specific embodiments, there is no intention to limit theinvention to the same. It will be understood that the foregoing is onlyillustrative of the principles of the invention, and that variousmodifications, alterations, and combinations can be made by thoseskilled in the art without departing from the scope and spirit of theinvention. Accordingly, it is not intended that the invention belimited, except as by the appended claims.

1. A method for tensioning a surgical elongate member, the methodcomprising: providing an implant having a elongate member connectedthereto, and a locking feature on the implant, wherein the lockingfeature circumferentially engages the elongate member to lock onto theelongate member; actuating a tensioner to regulate the tension on theelongate member; and locking the locking mechanism on the elongatemember to maintain a selected tension.
 2. The method of claim 1, whereinthe implant is a segmented intramedullary fracture fixation device. 3.The method of claim 1, wherein the locking mechanism comprises a collet.4. The method of claim 1, further comprising actuating the lockingmechanism actuator to lock the locking mechanism onto the elongatemember after regulating the tension on the elongate member.
 5. A methodfor tensioning a surgical elongate member, the method comprising:connecting a first location on an elongate member to an implant; lockinga locking feature onto a second location on the elongate member, whereinthe locking feature circumferentially engages the elongate member tolock onto the elongate member; actuating a tensioner to regulate thetension on the elongate member between the first location and the secondlocation; and locking a locking mechanism onto a third location on theelongate member.
 6. The method of claim 5, wherein the implant is asegmented intramedullary fracture fixation device.
 7. The method ofclaim 5, wherein the third location is between the first location andthe second location.
 8. The method of claim 5, further comprisingactuating the locking mechanism actuator to lock the locking mechanismonto the third location on the elongate member after regulating thetension on the elongate member.
 9. A method of treating a fracture in abone, comprising the steps of: providing an elongate fixation device,having a proximal end and a distal end; advancing the fixation devicealong a nonlinear path while the fixation device is in a flexible state,until the fixation device spans a fracture in the bone; engaging thebone with the distal end of the fixation device; transforming thefixation device from the flexible state to a substantially rigid state;axially shortening the fixation device to apply compression across thefracture; and locking the fixation device in the substantially rigidstate.
 10. The method of treating a fracture in a bone as in claim 9,wherein the axially shortening step and the locking step areaccomplished simultaneously.
 11. The method of treating a fracture in abone as in claim 9, wherein the axially shortening step is accomplishedfollowing the engaging step.
 12. The method of treating a fracture in abone as in claim 9, wherein the transforming step comprises proximallyretracting a tensioning element with respect to the proximal end. 13.The method of treating a fracture in a bone as in claim 12, wherein thelocking step comprises locking the tension element in a compressionlock.
 14. The method of treating a fracture in a bone as in claim 9,wherein the axially shortening the fixation device is decreases afixation device length by up to about 5 mm.
 15. A method of locking animplant in a rigid configuration, comprising the steps of: tensioning anelongate member disposed through two or more segments of an implant;locking the elongate member at a lock; and cutting the elongate memberproximal to the lock.